MEDICAL 


FROM  THE  LIBRARY  OF 
FRANK  BRANSON  PETRIE,  M.D. 


A  TEXT-BOOK 


OF 


CLINICAL  ANATOMY 


STUDENTS   AND    PRACTITIONERS 


„ 

BY 

DANIEL  N.  EISENDRATH,  A.B.,  MJX 

Professor  of  Clinical  Anatomy  in  the  Medical  Department  of  the  University  of  Illinois 

(College  of  Physicians  and  Surgeons);  Attending  Surgeon  to  the  Cook 

County  Hospital,  Chicago  ;  Professor  of  Surgery  in  the 

Postgraduate  Medical  School,  Chicago 

ERKATA. 

Page  203,  Fig.  61,   Legend.    SF,  for  "Splenic  flexure  of  colon,"  read  "Hepatic 

flexure  of  colon."    HF,  for  "Hepatic  flexure  of  colon,"  read  "Splenic  flexure 

of  colon." 
Page  205,  Fig.  62,  Legend.    13,  for  "Ascending      colon,"      read      "Descending 

colon."    14,  for  "Descending  colon,"  read  "Ascending  colon." 
Page  213,  Fig.  65,  Legend.  8,  for  "Ascending  colon,"  read  "Descending  colon." 

10,  for  "Descending  colon,"  read  "Ascending  colon." 


Beautifully  3f|llu0trateU 

&       ^      


PHILADELPHIA,   NEW  YORK,   LONDON 

W.   B.   SAUNDERS  &   COMPANY 
1903 


A  TEXT-BOOK 


OF 


CLINICAL  ANATOMY 


STUDENTS   AND    PRACTITIONERS 


DANIEL  N.  EISENDRATH,  A.B.,  MJX 

Professor  of  Clinical  Anatomy  in  the  Medical  Department  of  the  University  of  Illinois 

(College  of  Physicians  and  Surgeons)  ;  Attending  Surgeon  to  the  Cook 

County  Hospital,  Chicago  ;  Professor  of  Surgery  in  the 

Postgraduate  Medical  School,  Chicago 


beautifully  31llu0trateD 



PHILADELPHIA,   NEW  YORK,   LONDON 

W.   B.   SAUNDERS  &   COMPANY 
1903 


COPYRIGHT,   1903.   BY   W.   B.   SAUNDERS  &  COMPANY 


REGISTERED  AT  STATIONERS'  HALL,  LONDON,  ENGLAND 


PRESS    OF 
B.    SAUNDERS    &    COMPANY. 


^/v\ 


|f  IB 


PREFACE. 


MANY  changes  have  taken  place  in  the  teaching  of  anatomy  during 
the  past  twenty  years.  The  rapid  development  of  the  various  branches 
of  practical  medicine  and  surgery  has  necessitated  a  most  thorough 
preparation  in  the  fundamental  subjects,  such  as  anatomy,  physiology, 
chemistry,  and  pathology.  In  the  majority  of  our  medical  schools 
descriptive  anatomy  accompanied  by  dissections  is  taught  during  the 
first  two  years,  and  then  the  student  feels  that  he  may  consider  anatomy 
a  closed  chapter.  In  but  few  of  the  colleges  is  he  taught  to  take  a 
perspective  view,  or,  in  other  words,  to  study  Regional  or  Topographic 
Anatomy.  He  has  spent  many  hours  in  the  memorizing  of  nerves, 
arteries,  veins,  and  the  description  of  viscera,  but  he  is  unable  to  apply 
this  knowledge  to  clinical  work. 

The  primary  object  of  this  book  is  to  serve  as  a  bridge  for  both 
practitioner  and  student  from  the  descriptive  anatomy,  as  it  is  usually 
taught  in  the  first  two  years  of  a  medical  course,  to  its  daily  application 
at  the  bedside,  in  the  clinic,  or  in  the  operating  room. 

The  term  "CLINICAL  ANATOMY"  seemed  to  be  the  most  appropriate 
one  to  use  to  express  the  larger  field  which  the  subject  covers.  The 
term  was  first  employed  in  this  sense  by  Dr.  A.  D.  Bevan,  to  convey  the 
fact  that  clinical  anatomy  is  anatomical  knowledge  as  applied  to  every 
branch  of  clinical  work — i.  e.,  not  only  medicine  and  surgery  in  the 
narrower  sense,  but  all  the  specialties. 

In  teaching  this  subject  to  third  year  medical  students  the  author 
felt  the  need  of  a  text-book  which  should  cover  not  only  the  surgical  but 
also  the  medical  portion  of  the  subject,  and  he  hopes  that  the  work  will 
not  be  found  to  have  been  written  from  the  standpoint  of  the  surgeon 
alone. 

An  especial  attempt  has  been  made  to  encourage  both  practitioners 
and  students  to  examine  the  normal  human  body  during  life,  to  palpate 
and  outline  structures,  and  to  study  the  relations  of  nerves,  vessels, 
viscera,  etc.,  the  knowledge  of  whose  position  is  indispensable  to  every 
one  engaged  in  the  practice  of  medicine. 

It  has  not  been  deemed  advisable  to  take  up  the  details  of  anatomy, 

5 


6  PREFACE. 

since  this  book,  if  used  as  a  text-book,  is  intended  for  students  who  have 
finished  a  course  such  as  is  covered  by  the  standard  text-books  of 
anatomy. 

In  his  course  on  Clinical  Anatomy  the  author  insists  upon  surface 
anatomy  as  of  great  practical  value  to  the  student,  in  order  that  he  may 
become  accustomed  to  relations  as  found  in  practice. 

The  majority  of  the  illustrations  in  this  work  are  original.  Many 
of  the  surface  outlines  were  marked  upon  a  normal  artist's  model  and 
then  photographed.  Sections  of  joints  and  those  of  the  trunk  at  different 
levels  were  made  from  formalinized  cadavers,  with  the  kind  cooperation 
of  Professor  William  T.  Eckley,  to  whom  the  author  desires  to  express 
his  thanks.  In  order  to  render  the  photographs  desirable  for  repro- 
duction, it  was  necessary  in  most  cases  to  retouch  them. 

The  chapter  upon  the  Eye  was  written  by  Dr.  Mortimer  Frank,  for 
whose  valuable  assistance  in  the  preparation  of  illustrations  the  author 
also  desires  to  express  appreciation,  as  well  as  to  Drs.  W.  E.  Quine 
and  D.  A.  K.  Steele  for  their  encouragement.  Many  of  the  illustra- 
tions of  fractures  were  made  from  #-ray  pictures  kindly  lent  by  Mr. 
W.  C.  Fuchs.  Dr.  J.  S.  Brown  has  prepared  the  index. 

DANIEL  N.  EISENDRATH, 

October,  1903. 


CONTENTS. 


PAGE 

THE  HEAD n 

Examination  During  Life n 

General  Topography 12 

THE  CRANIUM 23 

Cranial  Contents 28 

Meninges  33 

THE  BRAIN _  41 

Cerebral  Centers 42 

Base  of  Skull 45 

Craniocerebral  Topography 47 

THE  EAR 48 

THE  MASTOID 54 

THE  FACE 60 

Examination  During  Life 60 

Anterior  Portion 67 

Lateral  Portion 76 

The  Mouth,  Pharynx,  and  Larynx 79 

The  Nose 90 

The  Eye 95 

THE  NECK 100 

Examination  During  Life 100 

Surface  Markings 101 

Regions  of 102 

Anterior 102 

Submaxillary  Triangle 109 

Carotid  Triangles 115 

Lateral  135 

THE  THORAX 138 

Examination  During  Life .__  141 

The  Lungs 146,  191 

The  Pericardium  153,  178 

Fractures  of  the  Sternum  and  the  Ribs 164 

The  Breasts _  176 

The  Diaphragm 178 

The  Heart 182 

The  Esophagus .182 

The  Arch  of  the  Aorta. __  _  187 

The  Venae  Cavae__  _  188 

The  Thoracic  Duct__  _  188 

The  Phrenic  Nerves _  188 

The  Pleurae ,189 

The  Trachea  .__  -  190 

The  Mediastinum _  192 

7 


8  CONTENTS. 

PAGE 

THE  ABDOMEN -  195 

Examination  During  Life -   195 

Surface  Markings -   196 

Regions  of -   199 

Walls  of -  215 

Linea    Alba -  219 

Relations  between  Nerve-supply  of  Abdominal  Viscera  and  of  Skin. _  .   223 

Abdominal  Incisions -   223 

Inguinal  Region  and  Hernia- _  -   225-234 

Femoral  Region  and  Hernia 234-236 

Umbilical   Hernia 236 

Iliac  Region.  __  -   237 

Lumbar  Region -   240 

The  Abdominal  Cavity  in  General- _  _   241 

The  Peritoneum -   241 

The  Liver.  __  -   250 

The  Gall-bladder  .__  -255 

The  Stomach  ___  -   256 

The  Small  Intestine. _  _   261 

The  Large  Intestine ,266 

The  Spleen -   275 

The  Pancreas    -   277 

The  Kidneys -  278 

The  Ureter -   284 

The  Pelvis  in   General -   287 

Relation  of  Pelvic  Viscera  in  the  Male _   288 

The  Male  Perineum 302 

Relations  of  Pelvic  Viscera  in  the  Female 305 

External  Genitalia  in  the  Female _  317 

Nerves  of  the  Abdominal  Cavity 318 

THE  UPPER  EXTREMITY 322 

Examination  During  Life 322 

Surface  Markings _  347 

The  Shoulder   Region  __  _  348 

The  Axilla _  352 

The  Brachial  or  Upper  Arm  Region  __  _  365 

The  Elbow  Region.  __  _  369 

The  Forearm _  377 

The  Wrist  and  the  Hand._  _  378 

Effects  of  Paralysis  of  the  Nerves  of  the  Brachial  Plexus _  391 

THE  LOWER  EXTREMITY.  __  _  398 

Examination  During  Life _  398 

Surface  Markings _  417 

Buttock  or  Hip  Region _  418 

Anterior  Thigh  Region ,422 

The  Hip-joint _  428 

The  Thigh  .  _  443 

The  Knee  Region _  447 

The  Leg  ....  .  454 

The  Foot _  467 

Ankle-joints  and  Joints  of  Foot _  472 

Nerve-supply   of   Lower   Extremities   and    Effects   of   Paralysis  of   Individual 

Nerves 482 


CONTENTS.  9 

PAGE 

THE  SPINE _  484 

Examination  During  Life _  484 

The  Spine  in  a  Clinical  Sense.-  _  486 

Normal   Movements  of _  491 

Normal  Lateral  Deviations  of —  _  492 

Pathology    of -  493 

The  Spinal  Cord  and  its  Membranes —  _  497 

Localization  of  Fi  nctions  in  Segments  of  Spinal  Cord  (Table)--  _  499 


INDEX 503 


CLINICAL  ANATOMY. 


THE  HEAD. 

Examination  of  the  Cranium  of  the  Living  Adult. — i.  Pick  up  the 
skin  of  the  scalp  between  the  fingers,  in  the  frontal  and  lower  portions  of 
the  temporal  regions  (non-hairy  portion  of  the  scalp),  and  note  how  much 
thinner  and  more  elastic  it  is  than  that  over  the  skull  (hairy  portion). 

2.  Slide  the  scalp  upon  the  underlying  skull  and  observe  the  move- 
ments of  the  scalp  caused  by  the  contractions  of  the  occipitofrontalis 
muscle. 

3.  Palpate  the  bony  prominence  situated  in  the. median  line  on  a 
level  with  the  upper  margins  of  the  orbit  and  just  above  the  root  of  the 
nose.     This  is  the  glabella. 

4.  Passing  outward  from  the  glabella  can  be  felt  the  supra-orbital 
ridges.     They  correspond  to  the  position  of  the  frontal  sinuses,  and  their 
lower  boundary  is  formed  by  the  supra-orbital  margin.     At  the  junction 
of  the  inner  and  middle  thirds  feel  the  notch  through  which  the  supra- 
orbital  nerve  emerges.     Pressure  upon  it  causes  a  dull  pain. 

5.  At  the  outer  end  of  each  supra-orbital  margin  palpate  the  ex- 
ternal angular  process  of  the  frontal  bone. 

6.  Just  above  the  supra-orbital  ridges,  and  separated  from  them  by 
a  slight  depression,  note  the  two  more  or  less  prominent  frontal  emi- 
nences.    They  are  of  no  clinical  importance. 

7.  Palpate   the   zygoma   along  its  entire  extent  from  the  external 
angular  process  to  the  ear.     Just  in  front  of  the  latter  one  can  feel  the 
pulsations  of  the  superficial  temporal  artery. 

8.  Palpate  the  temporal  ridge  over  the  side  of  the  skull  from  the 
external  angular  process  to  its  termination  behind  the  ear  in  the  mastoid 
process.     This  posterior  end  is  to  be  felt  as  a  slight  depression. 

9.  Feel  the  depression  on  each  side  of  the  skull  between  the  tem- 
poral ridge  and  the  zygoma;  it  is  the  temporal  fossa,  and  in  it  can  plainly 
be  felt  during  mastication  the  movements  of  the  temporal  muscle.     In 
many,  beyond  the  age  of  forty,  a  tortuous  anterior  branch  of  the  temporal 

ii 


12  THE    HEAD. 

artery  which  passes   obliquely  forward  across  the  temporal  region  is 
visible  here. 

10.  Palpate  the  mastoid  process  from  its  base  to  its  tip.     Passing 
almost  horizontally  backward  from  its  base  one  can  feel  the  superior 
curved  line  of  the  occipital  bone  as  a  ridge  which  terminates  behind  in 
the  median  line  of  the  skull  at  the  inion  or  external  occipital  protuber- 
ance.    At  about  its  middle  a  notch  can  be  felt  through  which  the  great 
occipital  nerve  passes  upward  to  the  skull.     Pressure  upon  this  causes  a 
dull  pain. 

11.  In  many  adult  skulls  one  can  feel  a  depression  in  the  median 
line  about  three  inches  above  the  inion,  or  occipital  protuberance,  which 
is  called  the  lambda.     It  corresponds  to  the  position  of  the  lesser  fonta- 
nelle.     On  either  side  of  it,  and  slightly  forward,  one  can  palpate  two 
bony  prominences — the  parietal  eminences. 

Examination  of  the  Cranium  of  the  Living  Infant. — i.  The  large 
and  small  fontanelles  are  to  be  felt  as  depressions  (see  Fig.  i)  which 
pulsate.  These  depressions  can  be  felt  up  to  the  end  of  the  second  year 
at  the  anterior  and  posterior  ends,  respectively,  of  the  suture  (sagittal) 
between  the  two  parietal  bones.  They  bulge  somewhat,  as  the  child 
cries,  owing  to  the  increase  of  intracranial  pressure. 

2.  Palpate   the    various    superficial    sutures    between    the    cranial 
bones — 

The  sagittal  between  the  two  parietals ; 

The  coronal  between  the  two  parietals  and  the  frontal ; 

And  the  lambdoidal  between  the  two  parietal  and  the  occipital 
bones. 

Note  how  in  infants  the  bones  slide  upon  each  other  and  also 
observe  their  great  elasticity,  owing  to  which  they  are  seldom  broken. 

3.  Note  the  more  rounded  form  of  the  infant's  as  compared  with 
the  more  oblong,  dolichocephalic  skull  of  the  adult  (see  Fig.  i). 

4.  Observe  the  lack  of  development  of  the  supra-orbital  ridges 
(frontal  sinuses)  and  mastoid  processes. 

General  Topography  of  the  Cranium  and  its  Coverings. 

The  head  is  divided  into  the  cranium,  or  skull  proper,  and  the  face. 
The  cranium,  or  skull  proper,  embraces  all  that  portion  of  the  head 
which  lies  above  a  line  passing  through  the  eyebrows  in  front,  the  external 
auditory  meati  laterally,  and  the  occiput  behind.  The  skin  covering  it 
is  called  the  scalp,  and  is  divided  into  a  hairy  and  a  non-hairy  portion 
(temporal  and  frontal  regions). 

The  bony  skull  contains  the  brain  and  its  membranes,  and  consists 


Fig.  i. — View  of  skull  of  adult  and  child  (at  full  term)  from  above.  In  the  adult 
skull  the  dotted  line  in  the  middle  shows  the  location  of  the  longitudinal  sinus  and  of  the 
fissure  between  the  two  hemispheres.  On  the  right  side  are  seen  the  convolutions  in  which 
are  situated  the  principal  motor  areas.  Those  of  the  leg  are  nearest  to  the  median  line, 
i.  e.,  highest;  those  of  the  arm  next,  and  those  of  the  face  lowest.  These  are  all  situated 
in  the  ascending  frontal  (A  F)  and  ascending  parietal  (A  P)  convolutions.  The  fissure 
of  Rolando  (F  R)  is  seen  running  downward  and  forward  between  these  two  convolutions. 
On  the  left  side  of  the  skull  the  method  of  determining  the  position  of  the  fissure  of  Rolando 
without  a  special  instrument  is  shown.  The  mark  X  is  a  point  midway  between  the 
glabella  and  inion.  The  fissure  is  found  by  taking  a  point  half  an  inch  behind  X  and 
measuring  an  angle  of  67  degrees  running  downward  and  forward.  In  the  view  of  the 
child's  skull  are  seen  two  fontanelles,  the  anterior  or  larger  at  L,  the  smaller  or  posterior 
at  F.  S,  sagittal  suture.  C.P.,  most  frequent  location  of  cephalhematomata  (on  the 
parietal  bones). 


TOPOGRAPHY    OF   THE   HEAD.  17 

of  a  more  convex,  or  arching  portion,  the  vault  or  vertex  or  skull  cap, 
and  a  horizontal  portion,  the  base.  The  close  relation  between  the 
scalp,  bony  skull,  and  structures  of  the  interior  of  the  cranium  can  be 
best  understood  by  a  reference  to  figure  2. 

The  scalp  is  seen  to  consist  of  three  layers:  (i)  The  cutaneo- 
aponeurotic,  or  outermost,  is  composed  of  the  skin  of  the  scalp,  the  sub- 
cutaneous connective  tissue,  and  the  aponeurosis  of  the  occipitofrontalis; 
(2)  the  second,  or  middle  layer  (subaponeurotic),  is  made  up  of  loose 
areolar  tissue  which  binds  the  outer  layer  to  the  (3)  third,  or  innermost 
layer, — the  pericranium, — which  is  an  almost  translucent,  thin  mem- 
brane, more  or  less  firmly  attached  to  the  outer  table  of  the  skull. 

These  three  layers  contain  a  rich  network  of  blood-vessels,  nerves, 
and  lymphatics,  principally  situated  between  the  aponeurosis  and  skin. 
A  great  many  branches  of  these  vessels  and  nerves  penetrate  the  skull 
and  communicate  with  those  of  the  interior,  so  that  hundreds  of  channels 
exist  for  infection  to  be  carried  to  the  meninges  and  brain.  Similarly, 
pain  due  to  intracranial  affections  (tumor,  abscess,  etc.)  is  often  referred 
to  the  corresponding  point  on  the  scalp,  and  is  of  great  assistance  in 
localization. 

The  cutaneo-aponeurotic,  or  outermost,  layer  consists  of  thick,  in- 
elastic skin,  firmly  attached  to  the  aponeurosis  of  the  occipitofrontalis 
by  a  closely  woven  network  of  connective  tissue  which  binds  these  three 
layers  so  firmly  that  they  can  be  considered  as  one  layer,  the  skin  moving 
with  the  aponeurosis.  In  the  temporal  and  frontal  regions  this  layer  is 
far  more  elastic  and  more  closely  resembles  that  of  the  face,  permitting 
of  greater  swelling  than  upon  the  hairy  portion  of  the  scalp.  Erysipelas 
of  the  scalp  and  similar  infective  processes  are  difficult  to  recognize  on 
account  of  the  fact  that  but  little  swelling  can  take  place  in  this  cutaneo- 
aponeurotic  layer  of  the  scalp.  The  connective  tissue  is  arranged  in 
bundles  which  run  more  or  less  vertically  inward  from  the  skin  to  the 
aponeurosis.  Between  these  lie  small  masses  of  fat,  hair,  and  many 
sebaceous  glands,  the  hairs  extending  as  far  as  the  aponeurosis.  The 
blood-vessels,  nerves,  and  lymphatics  lie  chiefly  in  this  layer,  so  that 
infection  and  sloughing  of  flaps  are  rare  after  scalp  wounds,  owing  to  the 
rich  anastomoses.  Hemorrhage  from  wounds  of  the  scalp  is  more  diffi- 
cult to  control  than  elsewhere,  on  account  of  the  rigidity  of  the  connective 
tissue,  keeping  the  vessels  open  and  permitting  them  to  retract  so  that 
ordinary  ligation  will  often  not  suffice,  transfixion  of  an  artery  being 
necessary. 

The  principal  vessels  and  nerves  which  supply  the  scalp  can  be  seen 
in  figure  3.  They  are: 


1 8  THE    HEAD. 

1.  Anterior Supratrochlear  nerve  and  frontal  artery. 

Supra-orbital  nerve  and  artery. 

2.  Lateral In  front  of  ear,  auriculotemporal  nerve 

and  superficial  temporal  artery. 
Behind  ear,  (a)  small  occipital  nerve  and 
posterior  auricular  artery,     (b)   Great 
occipital  nerve  and  occipital  artery. 

The  frontal  artery  nourishes  the  pedicle  of  a  rhinoplastic  flap,  and 
the  temporal  artery  serves  as  a  guide  to  the  anesthetist. 

From  the  above  it  will  be  seen  that  the  greater  portion  of  the  scalp 
is  supplied  with  sensation  by  the  fifth  nerve,  which  also  supplies  the  dura, 
so  that  pain  due  to  inflammation  or  pressure  upon  the  latter  is  often 
referred  to  the  scalp. 

The  lymphatics  (see  Fig.  4)  of  the  anterior  half  of  the  scalp  empty 
into  glands  situated  just  beneath  the  skin  of  the  parotid  region  and  into 
those  inside  of  the  parotid  gland  itself.  Those  of  the  posterior  half 
drain  into  glands  lying  behind  the  ear  (posterior  auricular)  and  along 
the  superior  curved  line  of  the  occipital  bone.  One  is  frequently  con- 
sulted for  enlarged  glands  in  children,  lying  just  in  front  of  and  behind 
the  ear,  for  whose  cause  one  should  always  examine  the  corresponding 
portion  of  the  scalp. 

The  veins  of  the  scalp  accompany  the  arteries  and  empty  into  the 
veins  of  the  face  and  neck,  especially  the  external  jugular.  These  sur- 
face veins  all  communicate  with  the  sinuses  of  the  dura  mater,  and  in- 
directly with  those  of  the  pia-arachnoid,  by  means  of  innumerable  small 
emissary  veins  which  pass  through  the  skull.  In  addition  there  are  a 
number  of  larger  ones.  These  are  (see  Fig.  5) : 

1.  One  between  the  frontal  vein  and  longitudinal  sinus. 

2.  One  between  the  nasal  vein  and  cavernous  sinus,  through  the 
ophthalmic  veins. 

3.  One  between  the  posterior  auricular  veins  and  the  lateral  sinus 
(mastoid). 

4.  One  between  the  occipital  veins  and  lateral  sinus. 

Not  infrequently  infection  will  spread  from  the  skin  of  either  the 
face  or  scalp  and  cause  a  thrombophlebitis  of  the  subcutaneous  veins. 
This,  by  direct  continuity,  will  spread  through  these  emissary  veins  into 
the  interior  of  the  skull,  causing  a  thrombosis  of  the  endocranial  sinus, 
with  resultant  pyemic  conditions,  or  it  may  cause  a  septic  meningitis. 

Beneath  the  cutaneo-aponeurotic  layer  is  the  subaponeurotic  layer. 
This  is  a  mere  loose  network  of  connective  tissue  binding  the  aponeurosis 
to  the  external  covering  of  the  skull  or  pericranium.  On  account  of  the 


Fig.  4. — Superficial  and  deep  lymphatics  of  bead  and  neck:  i,  Lymphatic  in  cheek. 
2,  Glands  in  front  of  ear  and  inside  of  parotid  gland.  3,  Submaxillary  glands.  4,  Sub- 
mental  glands.  5,  Posterior  auricular  glands.  6,  Superficial  lymphatics  along  sterno- 
cleidomastoid  muscle.  7,  Deep  lymphatics  along  carotid  sheath,  beneath  sternocleido- 
mastoid  muscle.  8,  Supraclavicular  glands.  9,  Anterior  mediastinal  glands.  10, 
Axillary  glands. 


21 


THE   CRANIUM.  23 

loose  arrangement  of  the  connective-tissue  fibers  in  this  layer,  collections 
of  blood  and  pus,  or  edema  due  to  any  cause,  are  most  apt  to  occur  in 
this  layer.  On  account  of  the  attachments  of  the  occipitofrontalis  to  the 
zygoma,  superior  curved  line,  and  supra-orbital  ridges,  the  spread  of  such 
fluids  is  limited  in  this  subaponeurotic  layer.  Hence,  the  best  place  to 
drain  this  layer  is  along  the  above-mentioned  line  of  attachment  of  the 
aponeurosis. 

Beneath  this  layer  is  the  external  periosteal  covering  of  the  skull, 
the  pericranium.  It  is  firmly  attached  in  the  adult  to  the  entire  skull, 
but  in  infants  is  only  firmly  adherent  along  the  line  of  the  sutures. 
Hence,  extravasations  of  blood  or  pus  rarely  occur  in  the  adult,  but  quite 
frequently  in  infants.  One  of  the  most  marked  examples  of  this  is  the 
so-called  blood  tumor  frequently  observed  after  birth  as  a  result  of  the 
use  of  forceps,  etc.,  and  called  cephalhematoma.  It  can  be  readily 
recognized  if  the  anatomic  fact  is  borne  in  mind  that  the  limits  of  the 
swelling  correspond  to  the  line  of  the  sutures.  One  of  the  most  frequent 
places  for  it  to  occur  is  over  the  parietal  bone  (see  Fig.  i). 

The  pericranium  is  in  reality  the  external  periosteum  of  the  skull, 
but  has  little  to  do  with  its  nourishment,  the  latter  being  chiefly  derived 
from  the  many  meningeal  vessels— to  be  described  below — lying  between 
the  dura  and  the  inner  table  of  the  skull;  so  that  the  destruction  of  the 
pericranium  does  not  cause  necrosis  of  the  skull,  as  would  happen  if  the 
periosteum  of  a  long  bone  were  stripped  off. 

The  scalp  is  frequently  the  seat  of  skin  diseases,  especially  of  eczema 
and  of  favus.  At  times  cutaneous  lesions,  especially  of  syphilis,  are 
most  characteristic  at  the  junction  of  the  hairy  and  non-hairy  portions 
of  the  scalp,  forming  the  so-called  corona  veneris. 

Primary  tumors  of  the  scalp  are  rare;  angiomata  (naevi)  occur  in 
infants,  especially  in  the  frontal  region.  They  may  involve  only  the 
capillary  vessels  or  the  subcutaneous  veins. 

Dilatations  of  the  arteries  of  the  scalp  are  apt  to  involve  many 
vessels,  especially  affecting  the  temporal  region,  forming  so-called  cirsoid 
aneurisms. 

The  Cranium. 

The  cranium  proper,  or  brain-case,  is  divided  into  a  vertex,  or  vault, 
and  a  base.  Together  they  inclose  the  brain  and  its  membranes.  The 
vertex  is  composed  of  two  layers  of  compact  bone,  the  outer  and  inner 
tables,  between  which  there  is  a  cancellated,  loose-meshed  bone — the 
diploe.  In  the  latter  there  is  a  rich  network  of  veins  communicating 
with  those  of  the  scalp  on  one  side  and  those  in  the  interior  of  the  cranium 


24  THE   HEAD. 

(sinuses)  on  the  other  (see  Fig.  2).  It  may  readily  be  seen  how  infection 
can  travel  along  these  veins  of  the  diploe  from  the  exterior  to  the  interior. 
In  the  adult  the  cranial  bones  are  firmly  united,  and  there  are  only  traces 
of  the  sutures.  The  bones  in  the  adult  possess  only  a  moderate  degree 
of  elasticity,  as  compared  with  those  of  children.  Hence,  a  fall  or  blow 
upon  the  head  in  the  latter  will  not  be  so  apt  to  produce  a  fracture.  The 
vertex  is  almost  uniformly  thick,  the  thinnest  places  being  in  the  temporal 
regions.  The  base  is  alternately  thin  and  thick,  and  it  is  more  likely  to 
be  broken  across  these  thinner  places.  The  base  of  the  skull  is  also 
weaker  on  account  of  the  many  foramina  for  the  passage  of  vessels, 
nerves,  and  the  spinal  cord  (see  Fig.  6). 

In  the  infant  the  bones  of  the  vertex  are  separated  by  spaces  which 
are  bridged  over  by  the  pericranium  and  dura  mater — the  latter  being 
more  universally  and  firmly  adherent  than  in  adults.  These  spaces  are 
called  sutures  (see  Fig.  i),  the  most  important  being  the  sagittal,  in  the 
median  line.  At  its  anterior  end  is  the  anterior  fontanelle,  and  at  its 
posterior  the  posterior  fontanelle.  The  anterior  fontanelle  is  at  the 
junction  of  the  sagittal  and  coronal,  the  posterior  at  that  of  the  sagittal 
and  lambdoidal  sutures.  These  openings,  or  fontanelles,  aid  in  deter- 
mining the  position  of  the  child's  head  during  birth.  They  are  closed, 
under  normal  conditions,  at  the  end  of  the  second  year,  but  when  a  child 
suffers  from  rachitis  (rickets)  they  remain  open  much  longer.  When  a 
condition,  to  be  described  later,  known  as  hydrocephalus  develops,  the 
fontanelles  are  increased  in  size,  bulge,  and  do  not  close  at  the  regular 
time,  and  the  sutures  are  widened.  The  sutures  in  the  infant's  skull 
permit  the  cranial  bones  to  slide  upon  each  other  and  allow  the  head  to 
be  moulded  for  its  passage  through  the  pelvis  during  parturition.  They 
also  permit  the  cranial  bones  to  be  separated  to  accommodate  them- 
selves to  the  rapidly  growing  brain.  When  they  become  ossified  too  early 
in  life,  it  interferes  with  the  growth  of  the  brain,  resulting  in  a  condition 
known  as  microcephalus. 

There  is  no  mark  externally  to  indicate  the  limits  of  any  of  the  bones 
of  the  vertex,  but  for  clinical  purposes  it  may  be  said  that  the  parietal 
and  temporal  bones  on  each  side  form  the  greater  portion  of  the  lateral 
wall  and  roof;  the  frontal,  the  anterior,  and  occipital  the  posterior  walls. 

There  is  similarly  no  external  sign  to  indicate  the  situation  of  any 
of  the  fossae  of  the  base.  In  general,  however,  it  may  be  said  that  the 
anterior  fossa  extends  as  far  back  as  the  anterior  end  of  the  zygoma, 
externally;  that  the  middle  fossa  lies  between  this  and  the  mastoid 
processes;  and  the  posterior  includes  all  of  the  base  behind  these  pro- 
cesses. 


a 

JQ 


THE  CRANIUM.  27 

The  cranium,  both  vertex  and  base,  is  frequently  the  seat  of  frac- 
tures, which  may  be  produced  by  either  direct  or  indirect  violence. 
They  vary  from  a  simple  crack,  or  fissure,  to  an  extensive  crushing  in, 
or  depression.  The  fracture  usually  involves  both  tables,  and  of  these 
more  of  the  inner  than  the  outer,  on  account  of  its  lesser  degree  of 
elasticity.  Fractures  of  the  vertex  are  most  frequently  the  result  of 
direct  violence,  and  most  of  those  of  the  base  are  due  to  the  same  causes 
(over  two-thirds);  namely,  a  direct  blow  upon  the  vertex,  causing  a 
fracture  extending  into  the  base,  so  that  the  latter  is  broken  at  its  weakest 
places.  Fractures  both  of  vertex  and  of  base  may  be  caused  by  indirect 
violence,  such  as  a  fall  upon  the  feet  or  a  blow  or  fall  on  the  chin,  but  this 
is  rare.  It  was  formerly  thought  that  a  fracture  could  be  produced  at  a 
point  opposite  to  the  place  struck,  by  contrecoup.  In  the  light  of  modern 
knowledge  we  now  believe  that  the  best  way  to  understand  fractures  of 
the  skull  is  to  assume  that  the  latter  is  an  elastic  sphere.  Fractures  can 
thus  be  produced  by  either  compression  or  bursting.  In  the  first  variety 
(compression  fractures)  the  bone  will  be  compressed  by  the  violence 
until  its  elasticity  is  exceeded  and  it  gives  way  or  breaks.  The  inner 
table  being  less  elastic,  breaks  first  and  more  extensively,  and  may  at 
times  be  broken  alone.  In  the  second  variety  the  elastic  sphere,  or 
skull,  changes  its  form  under  the  influence  of  the  force  like  a  rubber  ball 
would,  and  will  finally  yield  at  some  meridian  where  its  elasticity  has  been 
exceeded.  The  former  (compression)  fractures  occur  most  frequently 
on  the  vertex,  extending  often  into  the  base.  Were  the  skull  a  perfect 
spheroid,  with  uniform  thickness  and  power  of  resistance,  one  could 
calculate  where  a  fracture  would  be,  knowing  the  point  of  impact. 
But  as  stronger  and  weaker  portions  alternate,  especially  in  the  base, 
one  can  only  say  that  the  elasticity  is  more  likely  to  yield  at  such  thinner 
places,  and  we  find  clinically  that  fractures  through  the  orbital  plate  and 
through  the  occipital  bone  are  most  frequent  (see  Fig.  6),  involving  also 
the  apparently  more  solid  petrous  portion  of  the  temporal,  on  account  of 
the  bone  being  weakened  by  the  carotid  and  jugular  canals. 

The  symptoms  which  a  fracture  or  any  disease  of  the  bones  of  the 
skull  may  cause  through  injury  of  the  brain  and  its  membranes,  or  any 
of  the  nerves  or  vessels  which  lie  in  close  relation  to  the  bones,  will  be 
taken  up  in  the  section  upon  cranial  contents. 

Acute  or  chronic  inflammations  of  the  cranial  bones,  are  not  as  fre- 
quent as  in  the  long  bones  of  the  body.  Acute  osteomyelitis  is  very  rare, 
but  acute  inflammation  of  the  pericranium  (periostitis)  occurs  during 
the  secondary  stage  of  syphilis,  accompanied  by  violent  nocturnal  pains. 
Chronic  inflammation  as  the  result  of  the  ordinary  pyogenic  organisms 


28  THE   HEAD. 

may  occur  as  a  result  of  an  infected  fracture  of  the  vertex,  but  the 
necrosis  following  it  is  usually  not  very  extensive. 

Tuberculosis  and  syphilis  are  perhaps  the  most  frequent  causes  of 
inflammation  of  the  cranial  bones.  The  former  is  especially  frequent 
in  the  temporal  bone,  particularly  in  children.  Syphilis  causes  extensive 
necrosis  during  its  tertiary  stages,  which  may  involve  the  entire  thickness 
of  the  skull.  Both  of  these  diseases  may  give  rise  to  localized  or,  more 
rarely,  to  diffuse  inflammation  of  the  internal  or  periosteum  proper  (dura 
mater)  of  the  skull,  causing  pressure-symptoms  in  the  brain  and  upon 
the  cranial  nerves  at  the  exits  of  the  latter  (syphilitic  periostitis  and 
meningitis). 

Congenital  malformation  of  the  skull  is  most  frequently  a  gap  in 
either  the  frontal  or  the  occipital  bone,  rarely  in  the  parietal  bone. 
Such  a  fissure  may  be  mistaken  for  a  fracture.  In  the  frontal  bone  it  is 
usually  situated  close  to  the  glabella.  Through  such  an  opening  there 
may  be  a  hernia  or  protrusion  of  either  the  membranes  of  the  brain  or 
even  of  some  portion  of  the  brain  itself.  If  the  protrusion  contains  only 
membranes,  it  is  called  a  meningocele;  if  both  brain  and  membranes,  a 
meningoencephalocele;  and  if  in  addition  a  ventricle  (lateral),  hydren- 
cephalocele.  In  infants  they  may  be  recognized  by  their  situation  and 
the  fact  that  they  become  tense  and  more  prominent  when  the  child  cries. 
They  may  also  occur  after  fractures  of  the  skull. 

Acquired  malformations  of  the  skull  may  be  caused  by  rachitis. 
The  head  assumes  the  shape  of  a  box,  its  lateral  and  anteroposterior 
diameters  becoming  almost  equal.  Another  condition,  known  as 
craniotabes,  is  also  the  result  of  the  same  disease.  It  is  due  to  a  gradual 
absorption  of  bone,  especially  in  the  occipital  bone,  so  that  the  skull 
becomes  almost  translucent  at  these  places  and  feels  very  soft  to  the 
touch. 

Tumors  of  the  skull  bones  are  infrequent,  especially  primary.  Of 
the  latter  osteoma  and  sarcoma  are  by  far  the  most  common.  Secondary 
tumors,  either  by  metastasis  or  by  extension  from  the  brain  or  meninges, 
are  more  frequent. 

Cranial  Contents. 

The  cranium  incloses  the  brain,  its  membranes,  and  their  blood- 
vessels. It  has  numerous  foramina,  especially  at  the  base,  for  the  passage 
of  vessels  leading  to  and  away  from  the  brain  and  its  membranes,  as 
well  as  for  the  exit  of  the  cranial  nerves  and  the  spinal  cord.  It  also 
contains  the  blood-supply  of  some  of  the  end-organs  of  special  sense,  like 
the  eye  and  ear,  which  are  in  close  relation  to  the  cranial  cavity. 


Anterior  branch  of  middle 
meningeal  artery 


GassL-rian  ganglion 


Posterior  branch  of  middle 
meningeal  artery 

Superior  petrosal  sinus 


Sigmoid  sinus  |  Hypoglossal  nerve 

teral  situ 


Olfactory  nerve 


Optic  nerve 

Internal  carotid  arterv 


Facial  nerve 
WEf~~  Auditory  nerve 
__    SB      \'agus  nerve 
jjf^f —  Glossopharyngeal  nerve 
^f —  Spinal  accessory  nerve 


Lateral  sinus 


Fig.  6. — View  of  base  of  skull,  showing  relation  of  cranial  nerves,  carotid  and  middle  meningeal 
arteries,  and  sinuses  to  the  fossae.  This  illustration  shows  on  the  right  side  of  the  skull  the  most 
frequent  lines  of  fracture  at  the  base  of  the  skull. 


20 


Pia-arachnoid 

suppuration 


Subdural  foci 


Epidural  foi 


P'pidural  focus 
in  middle-ear 
disease 


Fig.  7. — Coronal  section  of  skull  through  middle  of  petrous  portion  of  temporal  bone 
(semi-diagrammatic),  to  illustrate  the  position  of  meningeal  suppurations,  especially 
with  reference  to  middle-ear  and  mastoid  disease.  The  illustration  also  serves  to  show 
the  course  of  the  principal  motor  tracts  through  the  internal  capsule  and  pons.  i,  Motor 
fibers  of  leg.  2,  Motor  fibers  of  arm.  These  can  be  followed  down  through  the  pons 
varolii  until  they  cross  in  the  pyramids  (8).  3,  Facial  fibers,  which  cross  in  the  pons, 
and  emerge  from  it  to  form  the  facial  nerve  (7).  4,  Internal  capsule.  5,  Focus  in  upper 
portion  of  pons,  causing  paralysis  of  the  face  and  extremities  of  the  same  side.  6,  Focus 
in  lower  portion  of  pons,  causing  paralysis  of  the  facial  on  same  side  of  body  as  lesion, 
and  paralysis  of  the  extremities  on  opposite  side  of  body.  9,  Jugular  vein  and  lateral 
(sigmoid)  sinus,  showing  the  close  relation  of  the  mastoid  cells  and  antrum  (10  and  n 
respectively)  to  the  temporosphenoidal  lobe,  cerebellum,  sigmoid  sinus,  and  its  continua- 
tion in  the  jugular  vein.  An  inspection  of  the  middle  ear  on  the  left  side  of  the  picture, 
and  of  the  mastoid  cells  and  antrum  upon  the  right  side,  will  give  an  idea  of  the  anatomic 
relations  of  middle-ear  suppuration  to  endocranial  structures. 


31 


CRANIAL    CONTENTS.  33 

The  membranes  are  the  dura,  pia,  and  arachnoid.  The  dura  (see 
Figs.  2  and  7)  forms  the  internal  periosteum  of  the  skull.  In  children  it 
is  more  closely  attached  both  at  the  vertex  and  base  than  in  adults,  espe- 
cially so  at  the  sutures.  It  sends  out  sheaths  or  prolongations  for  each 
of  the  cranial  nerves,  so  that  infection  may  readily  travel  along  these 
from  the  exterior  of  the  skull,  and  any  obstruction  to  the  flow  of  cerebro- 
spinal  fluid  within  these  sheaths  will  cause  symptoms  of  stagnation  to 
appear;  for  example,  the  choked  disc  in  the  optic  nerve  as  a  result  of 
tumors  or  abscesses  of  the  brain.  The  dura  is  composed  of  two  layers. 
The  outer  is  closely  applied  to  the  cranial  bones  and  is  separated  from 
them  only  by  numerous  meningeal  vessels  which  lie  in  grooves  in  the 
bone  and  supply  the  bone  and  dura  (see  Figs.  2  and  6).  The  inner  layer 
of  the  dura  is  smooth,  and  like  the  pleura  in  structure,  being  covered 
with  smooth  endothelium.  The  two  layers  of  the  dura  separate  at 
certain  points  to  form  sinuses  for  the  return  of  blood  from  the  brain  and 
the  cranial  bones  (see  Figs.  2,  6,  9,  and  10).  Many  of  these  lie  in  such 
close  relation  to  the  bone  that  they  may  be  torn  by  a  fracture;  e.  g.,  longi- 
tudinal, lateral,  and  cavernous.  Of  these,  the  lateral  is  least  frequently 
injured.  The  two  layers  of  the  dura  also  inclose  the  Gasserian  ganglion, 
which  it  is  important  to  remember  in  operations  for  the  removal  of  this 
structure  (see  Figs.  6  and  8).  The  inner  layer  of  the  dura  forms  a  mem- 
brane, the  falx  cerebri,  separating  the  two  hemispheres  in  the  median 
line;  and  also  forms  the  tentorium  cerebelli,  separating  the  posterior 
half  of  the  cerebrum  from  the  cerebellum  (see  Fig.  10).  The  middle 
meningeal  artery  enters  the  middle  fossa  through  the  foramen  spino- 
sum.  It  then  passes  across  to  the  vertex,  its  trunk  corresponding  (see 
Figs.  6,  9,  and  10)  externally  to  about  the  middle  of  the  zygoma.  Just 
above  this  point  it  divides  into  an  anterior  branch  which  passes  almost 
vertically  upward,  and  a  posterior  which  passes  obliquely  backward.  Its 
close  relation  to  the  skull  bones  renders  it  peculiarly  liable  to  injury 
through  a  fracture  of  either  base  or  vertex,  and  the  accumulation  of  a 
large  clot  of  blood  between  the  dura  and  the  skull  (epidural  clot,  in  Fig. 
7).  The  dura  itself  may  be  torn,  allowing  the  blood  to  become  more 
diffused  (subdural  hemorrhage).  In  either  case  compression  of  the 
underlying  brain  results.  On  account  of  the  firmer  attachment  of  the 
dura  to  the  skull  in  children,  epidural  hemorrhage  is  rare  at  this  age. 

When  any  portion  of  the  skull-cap  is  removed  during  life,  one  can 
see  a  distinct  pulsation  of  the  dura,  synchronous  with  the  respiratory 
movements.  This  is  not  due  to  the  pulsation  of  the  brain  itself  as  the  re- 
sult of  arterial  pulsation,  but  to  the  rise  and  fall  of  blood  pressure  caused 
by  expiration  and  inspiration  respectively.  This  pulsation  is  absent  or 


34  THE   HEAD. 

decreased  when  there  is  any  increase  of  intracranial  pressure,  such  as 
occurs  in  meningeal  hemorrhages,  tumors,  etc. 

The  other  two  membranes  of  the  brain  must  be  considered  as  one, 
called  the  pia-arachnoid,  it  being  impossible  to  separate  the  fine 
network  forming  the  pia  from  the  arachnoid,  whose  outer  surface  is 
smooth,  and  has  been  compared  to  the  visceral  layer  of  the  pleura,  the 
parietal  being  formed  by  the  smooth  inner  surface  of  the  dura.  The 
space  between  the  dura  and  the  pia-arachnoid  is  called  the  subdural 
space  (see  Figs.  2  and  7).  Collections  of  blood  and  pus  may  occur 
here  and  become  widely  diffused,  at  times  extending  to  the  base  and 
causing  death  through  pressure  upon  the  pons  and  medulla.  This 
subdural  space  is  continuous  with  that  of  the  spinal  cord,  so  that  in- 
fection may  rapidly  extend  along  it  to  the  cord,  and  vice  versa  (menin- 
gitis). The  subdural  space  contains  fluid  whose  origin  is  not  clear. 
In  cases  of  fracture  of  the  skull  when  the  dura  is  torn  it  may  escape 
through  the  wound. 

The  pia-arachnoid  bridges  over  the  depressions  or  sulci  between 
the  convolutions.  It  contains  an  elaborate  system  of  veins  and  arteries, 
between  which  floats  a  fluid  in  its  fine  meshwork  known  as  the  cerebro- 
spinal  fluid.  The  system  of  spaces  is  an  exceedingly  intricate  one,  and 
permits  of  free  communication  between  the  lymph  bathing  the  convexity 
of  the  brain  and  that  of  the  large  spaces  at  its  base,  thus  forming  a  sort 
of  water-bed  for  the  brain,  and  greatly  diminishing  the  effects  of  blows 
upon  the  head.  This  subarachnoid  space  communicates  with  the  same 
space  surrounding  the  spinal  cord,  and  also  with  the  ventricles,  through 
the  foramen  of  Magendie  in  the  roof  of  the  fourth  ventricle.  Hemor- 
rhages are  more  apt  to  occur  into  the  subarachnoid  space  in  children 
than  in  adults,  and  are  a  frequent  cause  of  death  after  forceps  opera- 
tions. The  foramen  of  Magendie  may  become  closed  during  infancy, 
so  that  the  fluid  within  the  ventricles  (where  the  cerebrospinal  liquid  is 
secreted)  accumulates,  causing  a  condition  known  as  hydrocephalus.  In 
this  the  lateral  ventricles  become  enormously  distended,  causing  pres- 
sure-atrophy of  the  surrounding  brain  and  producing  an  increase  in  the 
size  of  the  head  through  separation  of  the  bones  so  that  the  face  seems  like 
a  mere  parasite  upon  the  enormous  skull.  Various  unsuccessful  efforts 
have  been  made  to  relieve  this  condition  by  tapping  the  ventricles. 

All  varieties  of  infective  inflammation  of  the  meninges  may  occur, 
either  of  an  acute  or  a  chronic  type,  and  the  products  of  the  same  accumu- 
late in  the  epidural,  subdural,  or  subarachnoid  spaces  (see  Fig.  7),  being 
more  easily  diffused  in  the  second,  as  stated  above.  There  is  no  com- 
munication between  the  subdural  and  subarachnoid  spaces,  so  that 


Fig.  8. — Photograph  of  a  wax  model  of  the  skull,  showing  the  relations  of  the  cranial 
nerves,  i,  Gasserian  ganglion,  with  its  three  branches,  the  ophthalmic  (2),  the  superior 
maxillary  (3),  and  inferior  maxillary,  whose  principal  branches  are  the  lingual  (4),  and 
inferior  dental  (5).  Along  the  course  of  the  superior  maxillary  the  otic  ganglion  (10)  is 
to  be  seen.  6,  Facial  nerve  on  outer  side  of  ramus  of  lower  jaw.  It  can  be  followed 
backward  to  its  point  of  emergence,  stylomastoid  foramen,  where  its  distance  from  the 
surface  of  the  mastoid  process  is  to  be  noted.  7,  Vagus  nerve.  8,  Cervical  sympathetic, 
the  figure  8  being  placed  upon  the  superior  ganglion.  9,  Placed  upon  the  optic  nerve. 
Below  the  figure  is  to  be  seen  the  sixth  or  abducens  nerve;  above  it  the  third  and  fourth 
nerves.  By  following  these  nerves  backward  their  relations  to  the  Gasserian  ganglion 
and  internal  carotid  artery  and  cavernous  sinus  can  be  studied. 


35 


37 


Kpidural  space 


Anterior 

branch  of 

middle 

meningeal 

artery 

Frontal  sinus 


Sigmoid  sinus 


Lingual  nerve        Faucial  tonsil 

Fig.  10. — Sagittal  section  of  skull  to  show  the  distribution  of  the  middle  meningeal 
artery  as  viewed  from  the  interior  of  the  skull,  the  lateral  sinus,  and  the  relations  of  the 
accessory  sinuses,  lachrymal  duct  and  orifice  of  Eustachian  tube  to  the  nose.  This  illus- 
tration also  shows  the  position  of  the  pharyngeal  or  tonsil  of  Luschka  and  of  the  faucial 
tonsil,  i,  Orifice  of  Eustachian  tube  on  lateral  wall  of  nasopharynx.  2,  Sphenoidal  cells, 
opening  into  superior  meatus  (5),  at  point  indicated  by  white  line.  3,  Anterior  ethmoidal 
cells,  opening  into  middle  meatus.  The  middle  turbinated  bone  has  been  removed, 
leaving  only  its  point  of  attachment.  4,  Posterior  ethmoidal  cells,  opening  along  white 
line  into  superior  meatus  (5).  6,  Placed  in  middle  meatus  along  white  line,  the  upper 
end  of  which  indicates  the  opening  of  the  antrum  of  Highmore  into  the  middle  meatus. 
7,  Placed  over  a  white  line  which  indicates  the  opening  of  the  frontal  sinus  at  the  hiatus 
semilunaris  in  the  middle  meatus,  close  to  the  opening  of  the  antrum.  8,  Placed  in  front 
of  a  straw  indicated  by  a  white  line,  showing  the  opening  of  the  lachrymal  duct  into  the 
anterior  portion  of  the  inferior  meatus,  a  portion  of  the  inferior  turbinated  bone  (10) 
having  been  removed.  9,  Anterior  end  of  middle  turbinated.  n,  Inferior  meatus.  12, 
Pharyngeal  or  tonsil  of  Luschka  (adenoid  vegetations).  13,  Placed  at  junction  of  soft 
and  hard  palates. 


39 


CRANIAL    CONTENTS.  41 

infection  of  one  does  not  readily  spread  to  the  other.  An  inflammation 
of  the  dura  mater  is  called  a  pachymeningitis  interna,  or  externa, 
according  to  whether  it  is  situated  on  the  inner  or  outer  side.  An 
inflammation  of  the  pia-arachnoid  is  called  leptomeningitis. 

Epidemic  cerebrospinal  and  suppurative  meningitis  are  usually 
most  marked  in  the  pia-arachnoid,  and  quite  diffuse  over  the  convexity 
and  base.  The  more  chronic  types  of  inflammation,  like  tubercular 
and  syphilitic,  are  more  marked  at  the  base,  and  are  apt  to  cause  focal 
symptoms  through  pressure  on  nerve-trunks  (Fig.  6  and  7). 

The  leptomeninx,  as  the  pia-arachnoid  is  called,  receives  its  arterial 
supply  through  the  meningeal  branches  of  the  circle  of  Willis  at  the  base; 
its  veins  empty  into  the  sinuses  of  the  dura  (Fig.  2).  The  arteries  send 
in  branches  to  the  cortex  (see  Fig.  2),  thus  establishing  a  cortical  circu- 
lation quite  distinct  from  that  of  the  interior  of  the  brain  and  basal 
ganglia,  to  be  referred  to  later,  which  are  supplied  directly  from  the  ves- 
sels at  the  base.  Hence,  an  obstruction  in  the  latter  will  not  always 
interfere  with  the  circulation  in  the  cortex.  The  meninges  are  sup- 
plied by  the  fifth  cranial  and  the  sympathetic  nerves,  so  that  inflamma- 
tion of  or  pressure  on  them  causes  the  pain  to  be  referred  to  the 
corresponding  portion  of  the  scalp,  also  supplied  principally  by  the 
fifth  nerve.  This  is  of  importance  in  the  localization  of  intracranial 
lesions,  and  its  severity  is  an  index  of  the  degree  of  intracranial  pressure. 

The  brain  will  be  discussed  only  in  its  topographic  and  clinical  rela- 
tions. A  previous  study  of  its  anatomy  is  presupposed.  It  consists 
of  two  cerebral  hemispheres  which  are  held  together  by  a  broad 
commissure,  the  corpus  callosum  (see  Fig.  7).  They  contain  a  cortical, 
or  gray,  and  a  central,  or  white,  portion.  The  former  is  made  up  of 
nerve-cells  and  their  continuation  into  the  central  portion.  This  latter 
part  is  made  up  of  a  number  of  nerve-fibers  (internal  capsule)  serving 
to  connect  the  cortex  with  the  peripheral  portions  of  the  body,  and  also 
of  a  number  of  nuclei  of  gray  matter,  the  caudate  and  lenticular 
nuclei  and  optic  thalamus  (see  Fig.  10).  These  fibers  are  gathered 
together  at  the  base  of  the  brain  in  the  penducles  of  the  brain,  and  are 
continued  in  the  structures  at  the  base  known  as  the  pons  and  medulla. 
The  latter,  in  addition  to  serving  as  support  for  conducting  tracts  of 
fibers  from  the  cortex  and  the  gray  nuclei,  have  a  number  of  collections  of 
highly  organized  nerve-cells  in  which  many  of  the  cranial  nerves  arise. 

The  medulla  oblongata,  in  addition  to  having  the  nuclei  of  origin 
of  many  of  the  cranial  nerves,  is  the  seat  of  many  of  the  automatic 
centers,  like  those  of  circulation,  respiration,  sweating,  heat  regulation, 
etc. 


42  THE    HEAD. 

Separated  from  the  cerebral  hemispheres  by  a  fold  of  dura  (ten- 
torium)  is  the  cerebellum  (see  Figs.  7  and  10),  also  showing  two  hemi- 
spheres made  up,  like  the  cerebral,  of  a  cortical  gray  nerve-cell  and  a 
central  white  conducting  tract.  The  latter  fibers  pass  to  the  medulla 
and  pons,  and  have,  as  a  portion  of  their  function,  the  maintenance  of 
equilibration  and  co-ordination  through  their  connection  with  the  sen- 
sory tracts  arising  from  the  cord,  and  with  the  centers  of  hearing  in  the 
cortex. 

The  circulation  of  the  cerebrum  is  derived  from  two  sources — one, 
the  cortical  (see  Fig.  2);  and  the  other,  the  basal.  The  latter  vessels 
are  chiefly  derived  from  the  middle  cerebral  artery,  which  is,  in  reality, 
a  direct  continuation  of  the  internal  carotid.  The  branches  of  this 
vessel  ascend  directly  toward  the  central  portions  of  the  hemispheres 
which  they  supply,  and  are  end-arteries,  so  that  emboli  swept  away 
from  the  heart  into  the  carotids  and  lodged  at  the  beginning  of  the 
middle  cerebral  will  cut  off  the  blood-supply  of  these  basal  ganglia  and 
of  the  internal  capsule,  causing  paralysis  of  the  opposite  side  of  the  body 
(see  Fig.  7). 

Similarly,  a  thrombosis  of  these  vessels  will  cause  an  anemic 
necrosis.  These  vessels  are  frequently  the  seat  of  an  arterial  degenera- 
tion, or  of  minute  aneurism  formation,  the  result  of  various  general 
causes  (senility,  syphilis,  Bright's  disease,  etc.),  and  will  burst,  causing 
the  blood  to  escape  into  and  destroy  the  fibers  of  the  internal  capsule 
(see  Fig.  n,  internal  capsule). 

Physiologic  and  clinical  investigations  have  enabled  us  definitely  to 
locate  certain  centers  in  the  cortex  of  the  cerebrum  (see  Figs,  i  and  12). 
These  are: 

1.  Center  of  speech Third  left  frontal  convolution  in 

right-handed  people,  and  on 
right  side  in  left-handed  people. 

2.  Centers  of  motion For  leg,   in   upper  third   of    as- 

cending frontal  and  ascending 
parietal  convolutions  around 
fissure  of  Rolando. 

For  arm,  in  middle  third  of  same. 

For  face,  in  lower  third  of  same. 

3.  Center  for  hearing   (sen- 

sory aphasia) First    temporosphenoiclal    convo- 
lution. 

4.  Center  for  sight Occipital  lobe  (cuneus). 

5.  Center  for  general  sensa- 

tion   Probably  in  parietal  lobe. 


Cuneus  -< 


Parieto-occ.  fissure 


Post,  horn  lat.  ventricle  - 

Splenium  corp.  callos.  - 

Special  senses  - 


Optic  thalamus  ~ 

Internal  capsule  (Post. ' 
limb) 

Motor  tract,  leg  and  - 
sensory  fibers 

Knee  of  int.  capsule 
(motor  tracts  for 
arm  and  face) 


Ant.  limb  internal  cap- 
sule (frontal  fibers) 


Occipital  lobe 


Anterior  occip.  sulcus 
Visual  fibers 
Special  senses 

Insula 

External  capsule 
Capsula  extrema 

Claustrum 
Caudate  nucleus 


Asc.  limb  fissure  Syl- 
vius 


Fig.  n. — Horizontal  view  of  internal  capsule  (Ziehen). 


43 


CRANIAL   CONTENTS.  45 

A  glance  at  figures  7  and  n  will  give  some  idea  of  the  effect  of 
lesions  situated  at  various  portions  of  the  conducting  tracts  which  pass 
from  the  cortical  centers  to  the  extremities.  A  lesion  in  the  left  internal 
capsule  will  cause  motor  aphasia  and  paralysis  of  the  face,  arm,  and  leg 
on  the  right  side  of  the  body.  It  may  also  cause  disturbance  in  sensation 
on  the  opposite  side  of  the  body.  A  lesion  in  the  right  internal  capsule 
will  cause  the  same  symptoms,  except  loss  of  speech,  on  the  left  side  of 
the  body.  A  lesion  of  the  occipital  lobe  will  cause  blindness  in  the  cor- 
responding halves  of  the  field  of  vision.  If  on  the  left  side,  of  left  halves 
(left  lateral  hemianopsia).  A  lesion  affecting  the  motor  centers  around 
the  fissure  of  Rolando  will  cause  at  first  spasm  of  (through  irritation), 
and  later  paralysis  of,  the  face  and  extremities  of  the  opposite  side  of 
the  body.  Lesion  of  the  temporosphenoidal  lobe  will  cause  word  deaf- 
ness. Lesion  of  the  pons  will  give  rise,  according  to  its  location,  to 
paralysis  of  the  facial  muscles  on  one  side,  and  of  those  of  the  extremities 
on  the  opposite  side,  due  to  the  fact  that  the  latter  cross  at  a  lower  level 
(see  Fig.  7).  Lesions  of  the  pons  and  medulla  give  rise  to  symptoms 
involving  the  functions  of  the  fifth  to  twelfth  nerves  (see  below)  and  of 
the  higher  automatic  centers.  Lesions  of  the  cerebellum  cause  ataxia 
and  vertigo. 

The  following  portions  of  the  brain,  its  vessels  and  cranial  nerves, 
lie  in  close  contact  with,  or  pass  out  through,  the  fossae  of  the  base  of  the 
skull  (see  Figs.  6  and  10). 

Anterior  fossa i .  Frontal  lobes. 

2.  Olfactory  nerve. 
Middle  fossa i.  Temporosphenoidal  lobes. 

2.  Cavernous  sinus. 

3.  Internal  carotid  artery. 

4.  Optic  nerve  (II). 

5.  Motor  oculi  nerve  (III). 

6.  Trochlear  (IV). 

7.  Trigeminal  nerve  (V). 

8.  Abducens  (VI). 
Posterior  fossa i.  Cerebellum. 

2.  Occipital  lobes. 

3.  Lateral  sinus. 

4.  Seventh,    eighth,    ninth,    tenth, 

eleventh,  and  twelfth  nerves. 

The  symptoms  of  fractures  of  the  base  vary  with  the  fossa  injured, 
and  may  be  said  in  general  to  be : 


46  THE   HEAD. 

Anterior  fossa i.  Escape  of  blood  or  cerebrospinal 

fluid  through  nose  and  mouth 
(fracture  of  cribriform  plate 
of  ethmoid). 

2.  Anosmia. 

3.  Extravasation   under    conjunc- 

tivas. 

Middle  and  posterior  jossce . .  i .  Escape  of  blood  or  cerebrospinal 

fluid  from  ear. 

2.  Paralysis  of  second,  third,  fourth 

fifth,  and  sixth  nerves. 

3.  Formation  of  pulsating  exoph- 

thalmos  or  of  aneurism  ex- 
ternally due  to  injury  of  either 
cavernous  sinus  or  internal 
carotid,  or  of  both,  with  for- 
mation of  arteriovenous 
aneurism. 

4.  Facial  paralysis  due  to  injury  of 

seventh  nerve,  side  of  injury 
or  lesion. 

5.  Deafness  due  to  injury  of  eighth 

nerve. 

6.  Bulbar   symptoms   due   to   in- 

volvement of  ninth  to  twelfth 
nerves. 

7.  Symptoms  of  hemorrhage  due 

to  injury  of  either  middle  men- 
ingeal  artery  or  lateral  sinus 
(rare). 

The  same  symptoms  of  involvement  of  the  cranial  nerves  may  be 
caused  by  tumors,  periostitis,  etc.,  pressing  on  them  at  the  base  of  the  skull. 
Symptoms  of  injury  or  of  pressure  on  various  cranial  nerves  are: 

I.  Olfactory  nerve Loss  of  sense  of  smell. 

II.  Optic  nerve Blindness  in  corresponding  halves 

of  retina  (if  behind  commissure) 
of  each  eye  (hemianopsia). 
Blindness  in  corresponding  eye  (if 
in  front  of  commissure). 

III.  Motor  oculi  nerve  . . .  Ptosis — External   strabismus — Di- 

lated pupil. 

IV.  Trochlearis Inability  to  turn  eye  down  and  out- 

ward, so  that  double  vision  is 
complained  of. 

V.  Trigeminal Loss  of  sensation  over  cornea  and 

face. 
Loss  of  power  of  mastication. 


CRANIOCEREBRAL    TOPOGRAPHY.  47 

VI.  Abducens Internal  strabismus. 

VII.  Facial Paralysis  of  facial  muscles  and  of 

buccinator. 

VIII.  Auditory Deafness. 

IX.  to  XII. 

Glossopharyngeal,     Bulbar   symptoms:   indistinct   ar- 

Vagus, ticulation,    atrophy    of    tongue, 

Spinal  accessory,  .         difficulty  in  swallowing,  paralysis 

Hypoglossal, of  sternocleidomastoid  and  tra- 

pezius  muscles  (XI). 

Symptoms  of  injury  may  appear  as  a  result  of  a  tear  01  the  nerve  at 
the  base,  without  fracture. 

Craniocerebral  Topography. 

Relations  of  surface  of  skull  to  principal  blood-vessels,  fissures,  and 
centers  of  brain  (see  Figs,  i  and  12). 

The  fissure  of  Rolando,  around  which  lie  the  motor  centers, 
may  be  found  by  several  methods,  either  by  a  special  instrument,  a 
Rolandometer,  or  by  finding  a  point  which  is  one  centimeter  (J  inch) 
behind  the  center  of  a  line  extending  from  the  glabella  in  front  to 
the  inion  behind,  and  measuring  from  it  an  angle  of  67  degrees  down- 
ward and  forward. 

The  fissure  of  Sylvius,  below  which  lies  the  temporosphenoidal 
lobe.  Its  beginning  corresponds  to  a  point  four  centimeters  (i  J  inches) 
above  the  middle  of  the  zygoma,  and  from  this  it  extends  slightly  up 
and  backward. 

The  Middle  Meningeal  Artery. — Its  main  trunk  corresponds  to 
the  middle  of  the  zygoma  (Kocher).  A  little  above  this  (see  Figs.  9  and 
12)  it  divides  into  an  anterior  and  a  posterior  branch.  The  former, 
which  is  the  larger,  may  be  found  by  trephining  at  a  point  one  and  one- 
quarter  inches  behind  the  external  angular  process  of  the  frontal  bone, 
and  one  and  one-half  inches  above  Reid's  base  line  (a  line  drawn  through 
the  lower  border  of  the  orbit  and  external  auditory  meatus  to  the  occiput). 
Of  late  years  the  Krause-Hartley  flap  has  been  suggested  to  expose  the 
artery. 

The  superior  longitudinal  sinus  corresponds  to  a  line  drawn 
from  the  glabella  in  front  over  the  median  line  of  the  vertex  to  the  inion 
behind  (see  Figs,  i  and  12). 

The  lateral  sinus  (see  Figs,  i  and  12)  corresponds  to  a  line  drawn 
from  the  external  occipital  protuberance  to  the  base  of  the  mastoid 
process,  and  from  the  latter  line  to  its  tip  at  a  deeper  level. 


48  THE    HEAD. 

The  Ear. 

The  ear  is  divided  into  three  parts,  the  external,  middle,  and  internal 
ear.  Of  these  the  middle  ear,  or  tympanic  cavity,  is  of  the  greatest 
interest  clinically.  The  external  and  middle  portions  of  the  ear  serve 
as  a  most  ingeniously  constructed  receiving  and  conducting  apparatus 
for  sound-waves,  which  are  transmitted  to  the  receiving  portion  or 
internal  ear. 

The  external  ear  includes  the  portion  seen  externally,  and  com- 
monly known  as  the  ear,  and  a  canal  (the  external  auditory)  about  an 
inch  and  a  quarter  long,  partly  bony  (temporal  bone),  and  partly  carti- 
laginous; the  latter  is  a  continuation  of  the  cartilage  of  the  external  ear, 
and  both  bony  and  cartilaginous  portions  of  the  external  auditory  canal 
are  lined  by  skin,  which  is  an  extension  inward  of  that  of  the  scalp  and 
ear.  This  skin  is  of  very  fine  structure  and  firmly  attached  to  the  under- 
lying cartilage  and  periosteum,  so  that  a  small  furuncle  will  cause  but 
little  swelling,  and  yet  give  rise  to  a  disproportionately  great  degree  of 
pain,  owing  to  the  high  tension  under  which  the  pus  collects.  The 
external  ear  is  richly  supplied  with  blood-vessels,  principally  from  the 
temporal  and  posterior  auricular  arteries  and  veins,  so  that  wounds  heal 
readily.  Owing  to  the  above-mentioned  close  connection  between  the 
skin  and  underlying  cartilage,  only  moderate  subcutaneous  hemorrhage 
and  swelling  occur.  The  exposed  position  of  the  ears  causes  them 
to  be  the  seat  of  congelation  or  freezing  frequently.  Their  vascularity 
is  so  great  that,  as  in  the  scalp  and  face,  the  entire  ear  may  be  torn  off 
except  a  narrow  pedicle  which  contains  an  artery  and  yet  may  heal 
again. 

The  external  auditory  canal  is  in  close  relation  to  the  parotid  gland 
and  temporomaxillary  joint  in  front,  and  to  the  mastoid  cells  behind. 
By  placing  the  finger  in  the  ear  one  can  feel  the  movements  of  the  joint. 
The  relation  of  the  canal  and  mastoid  cells  causes  abscesses  of  these 
structures,  especially  of  the  parotid,  to  perforate  the  canal;  pus  escaping 
through  the  external  ear.  The  skin  of  the  canal  in  its  outer  portions 
contains*  many  fine  hairs,  sebaceous  and  ceruminous  glands.  These 
are  only  present  close  to  the  external  meatus,  so  that  furuncles  and  ear- 
wax  are  usually  found  in  the  outer  portion  of  the  canal.  The  skin  of 
that  portion  of  the  auditory  canal  close  to  the  membrana  tympani  is 
smooth  and  glistening,  and  contains  no  hair  or  glands.  The  canal  is 
directed  down  and  forward,  and  is  somewhat  bent  upon  itself,  so  that  it  is 
necessary  to  pull  the  external  ear  upward  and  backward  in  order  to  obtain 
a  clear  view  of  the  tympanic  membrane.  The  posterior  wall  of  the  canal 
receives  sensory  fibers  from  the  vagus,  so  that  foreign  bodies  inserted 


Fig.  12. — Relation  of  fissures  of  Rolando  and  Sylvius,  lateral  sinus,  convolutions, 
and  middle  meningeal  artery  to  skull.  M.A.,  Anterior  or  ascending  branch  of  the  middle 
meningeal  artery.  M.P.,  Posterior  or  horizontal  branch  of  the  middle  meningeal  artery. 
These  two  join  so  that  the  main  trunk  lies  about  opposite  the  middle  of  the  zygoma. 
F.R.,  Fissure  of  Rolando,  lying  between  4,  the  ascending  frontal,  and  5,  the  ascending 
parietal  convolutions.  F.S.,  Fissure  of  Sylvius,  that  is,  the  horizontal  limb,  i,  2,  and  3, 
First,  second,  and  third  frontal  convolutions.  6,  Parietal  lobe.  7,  Occipital  lobe.  8, 
9,  and  10,  First,  second,  and  third  temporal  convolutions.  L.S.,  Lateral  sinus.  The 
dotted  lines  show  that  portion  of  the  lateral  sinus  which  descends  on  the  inner  side  of  the 
mastoid  process  (sigmoid  sinus).  The  remainder  of  the  lateral  sinus  is  .shown  passing 
somewhat  horizontally  backward  beneath  the  occipital  lobe  (7).  A.M.,  Projection  of 
mastoid  antrum,  on  surface. 


49 


Fig.  13. — Coronal  section  of  skull  made  through  middle  of  petrous  portion  of  tem- 
poral bone  as  seen  looking  backward  into  posterior  fossa,  i,  Internal  jugular  vein  at 
its  beginning,  the  white  line  indicating  a  straw  which  was  passed  from  the  termination  of 
the  sigmoid  sinus  through  the  jugular  bulb  into  the  jugular  vein.  2,  External  auditory 
meatus,  at  whose  inner  end  one  sees  the  membrana  tympani  forming  an  angle  of  45  degrees 
with  the  horizon.  Attached  to  the  middle  of  the  membrana  tympani  can  be  seen  the 
malleus  and  incus  (to  malleus).  Above  these  bones  is  seen  the  epitympanic  space  (4). 
The  section  has  been  made  rather  obliquely,  so  that  on  the  right  side  of  the  skull  it  passes 
through  the  petrous  portion  of  the  temporal  bone  a  little  further  back,  showing  the 
mastoid  antrum  (3),  surrounded  by  the  mastoid  cells.  5,  Beginning  of  spinal  canal  at 
posterior  fossa  of  skull.  6,  Torcular  herophilii,  showing  the  point  of  meeting  of  the 
longitudinal  sinuses  and  the  lateral  sinuses  (8).  7,  Section  of  inferior  petrosal  sinus. 


THE   EAR. 


53 


into  the  ear  by  children,  or  ear-wax,  etc.,  may  cause  reflex  attacks  of 
coughing  and  vomiting. 

The  middle  ear  begins  externally  at  the  membrana  tympani,  a 
fine  membrane,  which  is  firmly  attached  to  a  ring  of  bone  (annulus 
tympanicus).  The  latter  is  complete  except  at  its  upper  portion,  and 
the  membrane  covering  this  little  gap  is  called  Schrapnell's,  being  less 
tense  than  the  rest.  The  tympanic  membrane  and  its  ring  form  an 
angle  of  forty-five  degrees  with  the  horizon  (see  Figs.  7  and  13),  and  it  is 
placed  obliquely  to  the  median  line  of  the  head.  Looked  at  through 
an  ear  speculum,  which  must  not  be  inserted  into  the  auditory  canal 
until  the  ear  has  been  pulled  upward  and  backward,  one  sees  the  handle 
of  the  malleus  attached  to  the  center  of  the  membrane.  One  can  follow 
the  handle  upward  and  forward  to  the  periphery,  where  the  more  flaccid 
portion  of  the  membrane  (Schrapnell's)  is,  corresponding  to  the  gap 
in  the  tympanic  ring  above  referred  to. 

Across  the  upper  portion  of  the  membrane  passes  the  chorda 
tympani  nerve  (branch  of  facial).  Hence,  one  should  always  perform 
paracentesis  in  the  lower  half.  Under  normal  conditions  the  membrane 
is  slightly  retracted,  the  center  of  the  depression  corresponding  to  the 
center  of  the  membrane  (umbo).  From  this  point  downward  and  for- 
ward one  can  see  a  triangular  glistening  area  with  its  base  toward  the 
periphery  (light  reflex).  Under  pathologic  conditions  the  membrane 
may  either  bulge  (pus  in  middle  ear)  or  be  markedly  retracted  (chronic 
catarrh). 

Perforations  of  the  membrane  are  most  frequent  in  the  lower 
quadrants. 

The  tympanic  cavity,  or  middle  ear,  contains  the  ossicles,  or  little 
bones,  which  transmit  vibrations  from  the  tympanic  membrane  to  the 
small  opening  in  its  inner  wall,  which  is  the  beginning  of  the  receiving 
portion  of  the  ear  (fenestra  ovalis  of  internal  ear,  Fig.  13).  It  is  lined 
by  mucous  membrane,  which  is  so  firmly  attached  to  the  periosteum 
that  inflammation  of  the  former  rapidly  spreads  to  the  latter,  causing 
necrosis. 

The  middle  ear  is  in  communication  with  a  complicated  series  of 
pneumatic  cells  in  the  mastoid  process,  and  also  with  the  nasopharynx 
through  the  Eustachian  tube  (Fig.  14). 

The  tympanic  cavity,  or  middle  ear,  may  be  compared  to  a  box 
with  primitive  anterior  and  posterior  sides.  The  outer  side  is  formed 
by  the  tympanic  membrane,  the  inner  by  the  bony  labyrinth  of  the  in- 
ternal ear. 

Its  upper  side  or  roof  (tegmen  tympani)  is  formed  by  a  thin   plate 


54  THE   HEAD. 

of  bone  which  separates  it  from  the  dura  mater  and  temporosphcnoidal 
lobe  (see  Figs.  7  and  13).  This  may  be  exceedingly  thin  at  times,  or 
even  have  openings  so  that  infection  can  spread  rapidly  through  it. 
The  floor  is  formed  by  a  similar  lamella  of  bone  separating  it  from  the 
internal  carotid  artery.  This  may  also  be  very  thin,  or  imperfectly 
developed  (Fig.  14). 

Its  anterior  and  posterior  walls  are  very  rudimentary.  In  the 
former,  or  really  at  the  anterior  part  of  the  inner  wall,  is  the  opening 
of  the  Eustachian  tube.  At  the  upper  back  portion  of  the  outer  wall, 
i.  e.,  above  the  tympanic  membrane,  'is  the  opening  of  the  mastoid 
antrum,  and  a  little  more  internally,  on  what  is  in  reality  the  posterior 
side  of  the  box,  is  the  ridge  under  which  the  facial  nerve  lies  as  it  passes 
through  the  petrous  portion  of  the  temporal  bone.  These  relations  are 
well  seen  in  figures  13,  14,  and  15. 

The  position  of  the  mastoid  antrum  can  be  understood  from  figures 
12  and  13.  It  varies  in  size  and  communicates  with  a  number  of  spaces 
(mastoid  cells)  in  the  mastoid  process  in  which  it  is  located.  It  opens 
into  the  upper  and  posterior  part  of  the  outer  wall  of  the  middle  ear. 
Just  back  of  the  mastoid  process  lies  the  lateral  sinus,  and  a  little  farther 
behind,  the  cerebellum  (Figs.  6  and  14).  These  relations  are  very  im- 
portant in  the  causation  and  spread  of  infection  of  the  middle  ear,  for 
the  following  reasons: 

1.  Micro-organisms   travel   along   the    Eustachian   tube   from   the 
nasopharynx  and  cause  suppurative  middle-ear  disease,  especially  after 
influenza,  scarlatina,  diphtheria,  etc.  (see/Fig.  14). 

2.  Chronic    nasopharyngitis    spreads    to    the    middle    ear    through 
continuity  of  mucous  membrane  along  the  Eustachian  tube,  and  is  one 
of  the  most  frequent  causes  of  middle-ear  catarrh  and  resultant  deafness. 

3.  The  position  of  the  facial  nerve,  so  close  to  the  tympanic  cavity 
and  mastoid  cells,  explains  its  frequent  involvement  in  inflammations  of 
either  or  both,  and  also  its  injury  in  mastoid  operations  (Figs.  6  and  15). 

4.  The  direct    communication  of   the    mastoid  cells  and  antrum 
with  the  middle  ear  permits  of  the  transmission  of  infection  from  one 
to  the  other. 

5.  The  proximity  of  the  brain  (over  fifty  per  cent,  of  all  abscesses 
in  the  brain  are  in  the  temporosphenoidal  lobe,  following  middle-ear 
infection),  of  the  dura,  and  of  the  lateral  sinus  to  the  tympanic  cavity 
and  mastoid  cells  renders  it  easier  to  understand  the  frequency  of  sinus 
phlebitis  and   thrombosis,  of  septic  meningitis,  and  of  epidural,  sub- 
dural,  cerebral,  and  cerebellar  abscesses,  after  suppurative  processes 
of  the  middle  ear  (see  Fig.  7). 


Fig.  14. — Horizontal  section  of  skull  to  show  Eustachian  tube,  etc.  The  posterior 
half  of  the  section  is  made  at  a  slightly  higher  level  than  the  anterior  half.  The  entire  sec- 
tion is  looked  at  from  above.  S,  Septum  of  nose,  i,  Two  white  lines  representing  probes 
which  show  the  point  of  opening  of  the  Eustachian  canal  into  the  nasopharynx.  They 
can  be  followed  back  upon  each  side  into  the  middle-ear  cavity,  indicated  by  the  figure 
10.  2,  Antra  of  Highmore.  3,  Sphenoidal  sinus.  4,  Internal  carotid  canal.  5,  Jugular 
bulb  at  termination  of  sigmoid  sinus  (6).  7,  Foramen  magnum.  8,  Middle  fossa  of 
skull.  The  black  line  indicates  the  course  of  the  middle  meningeal  artery.  9,  Groove 
for  Gasserian  ganglion.  10,  Cavity  of  middle  ear.  Its  relations  to  the  mastoid  and 
lateral  sinus  can  be  well  seen  on  the  right  side.  1 1,  Posterior  fossa  of  skull. 


55 


Facial  nerve 
Cartilaginous  por- 
tion  Eustachian 
tube  and  levator 
palati 


Stylopharyngeus 
Palatopharyngeus 


Lingual  tonsil 


Posterior  crico- 
arytenoid  muscle 


Antrutn  of  mastoid 


Mastoid  cells 
Middle  turhinated 

Inferior  turbin- 
ated 


Azygos  uvulae 
Tonsil 


Aryteno-epiglotti- 
dean  fold 


Aditus  laryngis 

Tubercle  of  San- 
torini 


Beginning  of 
esophagus 


Fig.  15. — Posterior  view  of  pharynx  and  larynx,  as  shown  in  a  coronal  section  of  the  skull  made 
through  the  level  of  the  mastoid  processes. 


57 


THE    EAR. 


59 


It  is  exceedingly  important  to  understand  these  anatomic  relations 
when  at  the  bedside  of  one  suffering  from  middle  ear  complications. 
The  mastoid  antrum  is  also  separated  from  the  middle  fossa  of  the  skull 
by  a  thin  plate  of  bone,  the  tegmen  antri,  so  that  infection  may  spread 
directly  from  it  to  the  overlying  brain'  meninges  and  lateral  sinus.  The 
location  of  the  mastoid  antrum  is  well  seen  in  figure  12,  also  its  relation 
to  the  lateral  sinus.  Externally,  it  corresponds  to  a  slight  depression 
just  behind  the  bony  elevation,  known  as  the  spine,  immediately  above 
the  upper  border  of  the  bony  external  meatus.  The  mastoid  process 
contains  a  large  number  of  cells  which  open  into  the  antrum.  In 
children  they  are  poorly  developed,  so  that  the  process  consists  chiefly 
of  the  antrum.  In  adults  the  periosteum  is  firmly  attached  to  the  process, 
so  that  pus  is  less  likely  to  escape  through  it  than  in  children.  In  open- 
ing the  antrum  of  the  mastoid  care  should  be  taken  not  to  chisel  too 
high,  for  fear  of  entering  the  middle  fossa;  nor  too  far  behind,  owing 
to  the  position  of  the  lateral  sinus;  nor  too  deep,  on  account  of  the 
proximity  of  the  facial  nerve  (Figs.  13,  14,  and  15).  If  one  desires  to 
establish,  as  is  frequently  done  in  chronic  suppurative  otitis  media,  a 
free  communication  between  the  antrum  and  middle  ear,  it  is  necessary 
to  chisel  away  the  posterior  wall  of  the  external  auditory  meatus. 

Thrombosis  of  the  lateral  sinus  sometimes  spreads  to  the  petrosal 
and  cavernous  sinuses,  but  more  frequently  into  its  terminal  vein, — the 
internal  jugular  (Fig.  13), — from  which  point  septic  emboli  may  be 
carried  first  to  the  lungs  and  later  cause  a  general  pyemia.  Such  a  con- 
dition of  the  jugular  shows  itself  as  a  tender  cord-like  swelling,  deeply- 
situated  along  the  sternomastoid.  The  lateral  sinus  has  been  frequently 
opened  and  septic  clots  removed  with  or  without  previous  ligation  of  the 
internal  jugular. 

The  Eustachian  tube,  like  the  external  auditory  canal,  is  com- 
prised of  bony  and  cartilaginous  portions.  It  is  lined  by  mucous  mem- 
brane continuous  with  that  of  the  middle  ear  on  one  end  and  with  that 
of  the  nasopharynx  on  the  other.  Nasal  catarrh  frequently  spreads 
along  it  to  the  middle  ear.  It  can  be  inflated  by  inserting  a  catheter  into 
its  opening  just  behind  the  posterior  nares  on  the  lateral  wall  of  the  naso- 
pharynx (see  Figs.  10,  14,  and  15). 

The  internal  ear  is  so  compact  and  so  deeply  situated  that  it  is 
not  accessible  to  any  operative  intervention.  In  certain  diseases 
(Meniere's)  there  is  marked  vertigo,  due  to  a  disturbance  of  its  semi- 
circular canals.  In  addition  to  these  canals,  which  with  the  cerebellum* 
have  as  their  probable  function  the  regulation  of  equilibration,  it  con- 
tains the  end-organs  of  the  auditory  nerve  in  the  cochlea.  Deafness,- 
due  to  disease  of  these  is  not  amenable  to  treatment. 


60  THE   HEAD. 

The  Face. 

The  lower  boundary  of  the  face  is  the  lower  border  of  the  lower  jaw 
and  a  line  continued  to  the  apex  of  the  mastoid  process  behind.  The 
upper  boundaries  are  the  supra-orbital  ridges  and  a  line  continued  from 
the  outer  end  of  each  along  the  upper  border  of  the  corresponding 
zygoma  to  the  little  cartilage  on  the  front  of  the  ear  (the  tragus). 

Examination  of  Face  during  Life. — i.  Palpate  the  lower  margin 
of  the  orbit  at  the  junction  of  its  inner  and  middle  thirds  and  feel  the 
notch  for  the  transmission  of  the  infra-orbital  vessels  and  nerve  (see 
Fig.  16).  Pressure  upon  this  causes  a  dull  pain  to  be  felt  over  the  upper 
jaw.  Draw  a  vertical  line  downward  from  the  supra-orbital  notch  noted 
above.  This  line  passes  directly  through  the  infra-orbital  notch,  and 
as  it  crosses  the  lower  jaw  one  can  feel  a  third  notch,  the  mental  foramen, 
through  which  the  mental  nerve  emerges,  so  that  the  three  principal 
cutaneous  branches  of  the  fifth  nerve  all  lie  close  to  the  skin  in  one 
straight  line.  It  is  important  to  remember  their  position  in  testing  for 
neuralgia  of  the  corresponding  branch  of  the  fifth  nerve. 

2.  Passing  the  fingers  outward  along  the  infra-orbital  margins,  note 
the  prominent  malar  bone.     It  is  continuous  behind  with  the  zygoma. 

3.  Palpate  the  entire  zygoma  again  and  note  how  it  is  formed  partly 
by  the  termination  of  the  temporal  ridge  from  the  external  angular 
process  of  the  frontal  bone  and  partly  by  the  zygomatic  process  of  the 
malar  bone.     It  becomes  much  thinner  as  it  passes  backward  toward  the 
ear.     At  its  posterior  end  feel  the  pulsations  of  the  temporal  artery. 

4.  Immediately  below  the  zygoma  one  can  feel  beneath  the  skin 
and  in  front  of  the  ear  a  soft  structure,  the  parotid  gland  (Fig.  16).     It 
is  readily  movable  upon  the  underlying  masseter  muscle,  which  can  be 
distinctly  felt  when  the  lower  jaw  is  brought  firmly  against  the  upper. 
The  anterior  border  of  the  muscle  is  especially  well  marked.     At  the 
junction  of  this  border  with  the  lower  border  of  the  lower  jaw  note  the 
pulsations  of  the  facial  artery.     Just  in  front  of  the  ear  and  a  little  below 
the  posterior  end  of  the  zygoma,  one  can  feel  the  movements  of  the 
condyle  of  the  lower  jaw  when  the  mouth  is  opened  and  closed.    This 
corresponds  to  the  situation  of  the  temporomaxillary  joint  (see  Fig.  17). 

5.  Passing  the  fingers  along   the   body  of  the  lower  jaw,  note  the 
prominent  anterior  portion,  or  symphysis  mentis,   and  observe  how 
much  thicker  the  skin  is  here  than  it  is  over  any  other  portion  of  the  face, 
except  the  parotid  region.     Feel  the  ridges  just  above  the  lower  border 
of  the  lower  jaw,  due  to  the  roots  of  the  various  teeth.     Note  the  naso- 
labial  fold,  a  slight  groove,  passing  from  the  outer  edge  of  the  nostrils 
in  a  curved  manner  to  the  angle  of  the  mouth  (see  Fig.  18).     Observe 


Fig.  1 6. — Surface  markings  of  superficial  structures  of  side  of  face  and  neck,  i,  2, 
and  3,  Points  of  emergence  of  supra-orbital,  infra-orbital,  and  mental  nerves  respectively. 
4,  Parotid  gland.  Just  above  the  figure  the  facial  nerve  is  seen  dividing  inside  of  the 
gland  into  six  principal  branches.  5,  Superficial  temporal  artery  dividing  into  its  anterior 
and  posterior  branches.  6,  Steno's  duct  opening  opposite  second  upper  molar  tooth. 
7,  Facial  artery.  8,  Sternocleidomastoid  muscle.  9,  Points  of  emergence  of  superficial 
cervical  and  spinal  accessory  (in  heavy  outline)  nerves  opposite  middle  of  posterior  border 
of  Sternocleidomastoid.  10,  Trapezius  muscle,  u,  Surface  marking  of  external  jugular 
vein  from  middle  of  clavicle  to  angle  of  jaw.  SM,  Submaxillary  triangle.  SC,  Superior 
carotid  triangle.  L,  Inferior  carotid  triangle.  OC,  Occipital  triangle.  SB,  Subclavian 
triangle. 


6 1 


Fig.  17. — Surface  markings  of  deeper  structures  of  face  and  neck.  V,  Fifth  nerve 
with  its  three  principal  branches  emerging  from  Gasserian  ganglion,  i,  Placed  upon 
condyle  of  lower  jaw,  the  thick  black  line  above  it  representing  the  temporomaxillary 
joint.  2,  Internal  maxillary  artery,  the  branch  passing  upward  representing  the  middle 
meningeal.  3,  Posterior  auricular  artery.  4,  Occipital  artery.  5,  Facial  artery.  6, 
Lingual  artery.  7,  Superior  thyroid  artery;  immediately  below  its  lower  end,  the  inferior 
thyroid  branch  of  the  subclavian  is  seen.  8,  Placed  just  above  the  bifurcation  of  the 
common  carotid  into  the  internal  and  external  carotids.  9,  Internal  jugular  vein.  Heavy 
black  line  between  8  and  Q  represents  the  vagus  nerve  lying  between  the  common  carotid 
artery  and  internal  jugular  vein,  but  at  a  deeper  level.  10,  Spinal  accessory  nerve  as  it 
passes  across  the  posterior  triangle  of  the  neck.  1 1,  Upper  border  of  apex  of  lung.  Note 
its  relation  to  12,  the  brachial  plexus.  13,  The  subclavian  artery.  14,  The  thoracic 
duct. 


Fig.  1 8. — Relation  of  accessory  sinuses,  nasal  bones  and  cartilages,  canaliculi  and 
nasal  ducts,  and  sac  to  surface.  Projection  upon  surface  of  outer  margins  of  orbital 
cavity,  of  conjunctival  sac,  and  of  globus  oculi  upon  surface.  A,  Antra  of  Highmore. 
F,  Frontal  sinuses.  The  white  cross  above  the  right  upper  lid  shows  the  relation  of  the 
supra-orbital  nerve  to  the  frontal  sinus.  The  black  cross  just  beneath  the  lower  lid  indi- 
cates the  relation  of  the  infra-orbital  nerve  to  the  antrum.  N,  Nasal  bones,  i,  Pro- 
jection of  margin  of  orbit  upon  surface.  2,  Projection  of  eyeball  (globus  oculi)  on  surface. 
3,  Projection  of  conjunctival  sac  upon  surface.  4,  Lachrymal  sac.  5,  Nasal  duct. 
From  the  lachrymal  sac  to  the  inner  ends  of  both  eyelids  the  lachrymal  canals  can  be 
seen  terminating  at  the  eyelids  in  the  puncta  lachrymalia.  6,  Lateral  cartilage  of  nose. 
Between  the  cartilage  of  each  side  (indicated  by  transverse  lines)  is  the  cartilaginous 
portion  of  the  septum,  upon  which  they  rest.  7,  Alar  cartilages. 


THE    FACE.  67 

the  movements  of  the  muscles  of  expression:  the  depressors  and  levators 
of  the  lips,  the  circular  muscle  of  the  mouth,  the  dilators  and  com- 
pressors of  the  nostrils,  the  circular  muscle  of  the  eyelids,  and  those 
which  raise  the  eyebrows. 

6.  Observe  the  contour  of  the  lips  and  the  depression  in  the  center 
of  the  upper  lip,  known  as  the  filtrum.     The  demarcation  between  the 
red  mucous  membrane  of  the  lips  (vermilion  border)  and  the  skin  of 
the  face  is  quite  sharp.     Palpate  the  body  of  the  upper  jaw  on  each  side 
below  the  infra-orbital  margin  and  malar  bone;  note  again  the  promi- 
nences due  to  the  roots  of  the  teeth.     Just  above  one  of  these,  running 
upward  from  the  canine  teeth  on  each  side,  is  a  ridge  known  as  the  canine 
ridge  or  eminence,  above  which  lies  the  antrum  of  Highmore  (Fig.  18). 

7.  Just  below  the  glabella  palpate  the  two  small  nasal  bones  and 
note  that  they  extend  downward  only  as  far  as  the  level  of  the  inner 
canthus  of  the  eye  (Fig.  18).     From  this  point  downward  palpate  the 
lateral  cartilages  of  the  nose,  which  form  the  lower  portion  of  its  roof. 
Note  how  they  are  separated  in  the  median  line  by  the  cartilaginous 
septum.     They  do  not  extend  down  to  the  lower  border  of  the  nose, 
but  only  about  half-way.     Palpate,  in  the  median  line  again,  the  carti- 
laginous septum  and  observe  that  it  extends  almost  to  the  tip  of  the  nose. 
Take  up  the  wings  or  alae  nasi  between  the  ringers;  note  how  elastic 
they  are,  due  to  the  more  flexible  triangular  cartilages  which  give  them 
their  form.     Observe  at  the  same  time  the  fact  that  the  skin  over  the 
nose  is  not  very  elastic  and  is  very  thin. 

In  children,  on  account  of  the  lack  of  development  of  the  accessory 
sinuses  of  the  nose,  the  bones  of  the  face  are  less  prominent  than  in  the 
adult.  In  both  children  and  old  people — owing,  in  the  case  of  the 
former,  to  the  nondevelopment  of  the  teeth,  and  in  old  people  to  atrophy 
— the  lower  jaw  is  to  be  felt  as  a  mere  strip  of  bone. 

The  face  can  be  divided  into  two  regions — an  anterior  and  a  lateral. 
The  former  includes  all  of  that  portion  which  lies  below  the  supra- 
orbital  ridges,  above  the  lower  border  of  the  lower  jaw,  and  in  front  of 
a  line  drawn  on  each  side  from  the  malar  bone  downward.  The  lateral 
or  parotid  region  is  bounded  by  the  just  mentioned  line  in  front,  by  the 
zygoma  above,  and  by  the  lower  border  of  the  lower  jaw  and  its  con- 
tinuation to  the  tip  of  the  mastoid  process  behind. 

Anterior  Portion,  or  Face  Proper. — The  skin  is  finer  and  more 
elastic  than  that  of  the  scalp  or  of  the  parotid  region.  It  contains  a 
large  number  of  sebaceous  glands,  especially  around  the  alae  nasi  and 
the  angles  of  the  mouth,  which  are  frequently  the  seat  of  acne.  The 
subcutaneous  tissue  is  loosely  arranged,  and  permits  of  great  swelling, 


68  THE    HEAD. 

especially  around  the  eyes  and  lips,  either  as  a  result  of  infection  or  any 
form  of  edema  due  to  a  systemic  disease — for  example,  nephritis. 

The  skin  is  so  elastic  that  it  is  well  adapted  for  plastic  operations. 
These  must  frequently  be  performed  in  the  correction  of  congenital 
malformations,  such  as  harelip,  etc.,  or  for  the  deformities  due  to  cica- 
trices, the  result  of  burns,  of  cancrum  oris  (a  form  of  gangrene  of  the 
cheeks  following  marasmus  and  measles),  or  those  remaining  after  the 
removal  of  growths. 

Immediately  beneath  the  skin  and  intimately  attached  to  it  are  the 
muscles  of  expression.  These  are  separated  from  it  only  by  a  layer  of 
fat,  which  is  most  abundant  over  the  buccinator.  They  are  all  supplied 
by  the  seventh  or  facial  nerve,  and  may  be  divided  into  three  groups 
(see  Figs.  8  and  16): 


Fig.   19. — Facial  palsy  of  left  side,     i,  Bilateral  attempt  to  raise  eyebrows;   2,  bilateral 
attempt  to  close  eyes;   3,  smiling  (Church). 

1.  Those  which  open  and  close  the  eyelids  and  raise  the  eyebrows 
— namely,  the  eye  group. 

2.  Those  which  dilate  or  contract  the  nostrils — the  nasal  group. 

3.  Those  which  open  and  close  the  lips  or  depress  the  angles  of  the 
mouth — the  buccolabial  group. 

In  a  paralysis  of  the  seventh  nerve  distal  to  its  exit  from  the  brain 
all  three  groups  are  involved.  This  is  spoken  of  as  a  peripheral  form, 
and  may  be  due  to  injury  or  disease  of  the  facial  nerve  either  during  its 
passage  through  the  temporal  bone  or  after  the  nerve  leaves  the  stylo- 
mastoid  foramen.  In  this  peripheral  form  the  nasolabial  fold  is  effaced, 
the  angle  of  the  mouth  on  the  paralyzed  side  droops,  and  the  eyelids  do 
not  close,  thus  leaving  the  eyeball  exposed  (lagophthalmus).  When 
the  patient  is  asked  to  smile  or  show  his  teeth,  the  paralyzed  side  remains 
motionless  (see  Fig.  19). 


THE    FACE.  69 

In  the  central  form  only  the  lower  two  groups — the  nasal  and  bucco- 
labial — are  paralyzed,  so  that  the  eyelids  can  be  opened  and  closed,  but 
the  muscles  of  the  lips  cannot  be  moved,  and  the  breathing,  if  the  patient 
is  unconscious,  is  stertorous,  owing  to  the  paralysis  of  the  buccinator, 
which  permits  the  cheek  on  the  paralyzed  side  to  be  blown  outward 
during  expiration. 

It  is  not  quite  clear  why  there  should  be  a  difference  between  a 
central  and  a  peripheral  facial  paralysis,  from  an  anatomic  standpoint. 
It  is  probably  due  to  the  fact  that  the  fibers  of  the  facial,  which  supply 
the  muscles  of  the  eyebrows,  etc.,  are  derived  from  another  cranial  nerve 


Fig.  20. — Double  hare-lip  and  cleft  palate.  The  prominence  on  the  left  side  of  the 
deformity  shows  the  protruding  intermaxillary  bone,  with  the  skin  of  the  median  line  of 
the  lip  covering  it  (skin  of  frontonasal  process). 

and  enter  into  the  formation  of  the  facial  after  it  leaves  the  brain,  so 
that  hemorrhage  into  the  internal  capsule  or  into  the  pons — that  is,  any 
lesion  affecting  the  facial  nerve  prior  to  its  exit  from  the  brain — affects 
only  the  lower  two  groups;  whereas,  any  condition  involving  the  nerve 
after  its  exit  from  the  brain  affects  the  three  groups. 

A  frequent  deformity  in  connection  with  the  upper  lip  is  hare-lip 
(Fig.  20).  It  is  often  associated  with  a  cleft  palate.  The  palate  is 
formed  in  the  embryo  by  the  union,  in  the  median  line,  of  two  processes 
—the  superior  maxillary  on  each  side,  offshoots  of  the  first  branchial  or 
mandibular  arch,  and  the  fronto-nasal  process.  When  they  fail  to  unite, 
a  gap  or  defect  is  left  which  may  be  exactly  in  the  median  line,  or  lateral 


70  THE    HEAD. 

to  it  (cleft  palate).  The  skin  covering  these  bony  processes  may  also 
fail  to  unite,  and  a  similar  defect  occurs  in  the  upper  lip  (hare-lip).  The 
latter  is  most  frequent  on  the  left  side,  extending  into  the  nostrils,  but  it 
may  be  bilateral.  It  may  or  may  not  be  associated  with  a  cleft  palate. 

In  the  illustration  the  inter-  or  premaxillary  bone,  which  corresponds 
to  the  lowermost  portion  of  the  nasof rental  process,  is  seen  deviated 
toward  the  left,  and  covered  by  the  skin  corresponding  to  the  same 
process. 

The  lips  are  covered  with  a  mucous  membrane  which  is  continuous 
with  that  of  the  mouth.  The  color  of  the  lips  is  a  direct  reflection  of 
the  condition  of  the  circulation,  except  in  those  who  have  been  exposed 
to  the  vicissitudes  of  the  weather.  When  oxygenation  is  deficient,  they 
are  bluish  or  cyanotic.  Under  normal  conditions  they  are  of  a  bright 
reddish  color.  In  conditions  of  anemia  they,  like  the  other  visible 
mucous  membranes, — for  example,  the  conjunctiva?,  palate,  gums,  etc., 
— are  of  a  whitish  color.  Their  junction  with  the  skin  of  the  face  is  a 
frequent  seat  of  epithelioma,  especially  in  the  lower  lip. 

Carcinoma  is  not  infrequently  found  in  the  human  body,  where 
one  variety  of  epithelium  undergoes  transition  into  another.  Malignant 
processes  are  very  apt  to  begin  here,  owing,  probably,  to  the  inclusion 
of  a  certain  number  of  cells  at  the  junction  of  the  two  varieties  (lips,  cervix 
uteri,  anus,  cardiac  end  of  stomach). 

A  form  of  skin  eruption  known  as  herpes  is  often  seen  around  the 
corners  of  the  mouth,  consisting  of  a  group  of  fine  vesicles.  Extra- 
genital  chancres  must  always  be  thought  of  when  a  firm,  hard,  slightly 
excavated  ulcer  is  situated  upon  the  lips.  The  frequency  of  slight 
fissures  or  cracks  here  offers  a  favorable  atrium  for  syphilitic  infection. 

The  chief  vessel  supplying  the  skin  and  underlying  tissues  of  the 
anterior  region  is  the  facial  artery  (see  Figs.  16  and  17).  Its  course  is 
represented  by  a  line  drawn  from  the  anterior  border  of  the  masseter 
muscle  (at  its  attachment  to  the  lower  jaw)  to  the  inner  angle  of  the  orbit. 
It  gives  off  branches  to  the  lips  (coronary),  side  of  the  nose,  etc.  Its 
anastomoses  are  so  free  that  infection  rarely  follows  a  wound  of  the 
face,  and  even  the  most  extensive  incisions  heal  by  first  intention. 

The  artery  is  accompanied  by  the  facial  vein,  which  receives  blood 
from  the  orbit  (ophthalmic  vein)  and  face.  In  severe  cases  of  infection, 
especially  in  furuncles  of  the  upper  lip,  it  may  become  the  seat  of  a 
septic  thrombophlebitis,  which  can  extend  inward  to  the  cavernous 
sinus,  or  downward  into  the  external  jugular,  into  which  it  empties. 

The  nerve-supply  of  the  anterior  region  is  derived  from  the  fifth 
and  seventh  nerves.  The  former  furnishes  all  of  the  nerves  of  sensa- 


Fig.  21. — Anterior  view  of  the  areas  of  distribution  of  the  sensory  nerves  of  the  skin  i  shown  on 
the  left  side  of  the  body),  and  distribution  of  sensation  according  to  segments  of  the  spinal  cord 
( shown  on  the  right  side  of  the  body),  i,  Ophthalmic  nerve.  2,  Superior  maxillary  nerve.  3,  In- 
ferior maxillary  nerve.  The  points  of  exit  of  the  supra-orbital,  infra-orbital,  and  mental  nerves  are 
shown  by  the  markings  X.  4,  Points  of  exit  of  the  anterior  intercostal  branches  of  the  intercostal 
nerves.  5,  Points  of  exit  of  the  lateral  branches  of  the  intercostal  nerves.  6,  Intercosto-humeral 
nerve.  A.M.  and  S.C.,  Area  of  distribution  of  the  great  auricular,  superficial  cervical,  and  supra- 
clavicular  branches  of  the  cervical  plexus.  C,  Circumflex  nerve.  W.  Nerve  of  Wrisberg.  I.C.,  In- 
ternal cutaneous  area.  M.S.,  Musculospiral  area.  M.C.,  Musculoculaneous  area.  U,  Ulnar.  M, 
Median.  R,  Radial.  (",.('..  (ienitocrural  area.  The  nerve  is  seen  as  distributing  its  branches  to  the 
genital  regioti  and  to  the  upper  portion  of  the  thigh.  E.C.,  External  cutaneous  area.  1. 1.,  Ilio-in- 
gninnl  area.  I.C.U.,  Internal  cutaneous  area  of  the  thigh.  M.C.U.,  Middle  cutaneous  of  thigh.  I.S.. 
Internal  saphenous.  P,  External  popliteal  branches  area.  On  the  right  side  the  division  according 
to  segments  is  seen,  the  letters  C,  D,  L,  and  S  standing  respectively  for  cervical,  dorsal,  lumbar,  and 
sacral  segments  of  the  cord.  On  the  right  side,  from  the  fourth  dorsal  to  the  twelfth  dorsal  (inclu- 
sive), the  maximum  points,  according  to  Head,  of  the  abdominal  viscera  are  shown  in  relation  to  the 
spinal  segments.  iSt-c  Abdomen.) 

5  7i 


Fig.  22. — Coronal  section  of  skull  to  show  frontal  sinuses  and  antra  of  Highmore. 
i,  Frontal  sinuses.  On  the  right  side  a  probe  is  seen,  indicating  the  position  of  the 
opening  of  this  side.  2,  Antra  of  Highmore.  On  the  right  side  a  probe  is  seen,  indi- 
cating its  opening  into  the  middle  meatus.  Upon  the  left  side  the  communication  referred 
to  in  the  text  as  occasionally  existing  between  the  ethmoidal  cells  and  the  antrum  is  shown 
by  the  probe.  3,  Ethmoidal  cells.  4,  Middle  turbinated  bone.  5,  Inferior  turbinated 
bone.  6,  Deviation  of  septum  to  right.  7,  Hard  palate.  8,  Globus  of  eye.  9,  Ex- 
ternal rectus  muscle.  10,  Inferior  rectus  muscle,  n,  Internal  rectus  muscle.  12,  Supe- 
rior oblique  and  superior  rectus  muscles. 


73 


THE   FACE. 


75 


tion;  the  latter,  those  of  motion.  The  ophthalmic  branch  of  the  fifth 
supplies  the  upper  third  (forehead),  the  superior  maxillary  the  middle, 
and  the  inferior  maxillary  the  lower  third  (see  Fig.  21)  through  their 
supra-orbital,  infra-orbital,  and  mental  branches  respectively.  The 
foramina  of  exit,  as  mentioned  above,  are  in  one  straight  line  (see  Fig. 
1 6)  drawn  from  the  junction  of  the  inner  and  middle  thirds  of  the 
supra-orbital  margin  downward.  The  lymphatics  close  to  the  median 
line  drain  into  the  submental;  those  more  laterally  into  the  submaxil- 
lary  glands  (see  Fig.  4). 

The  bones  of  the  face  lie  immediately  beneath  the  skin,  which  is 
freely  movable  on  them.  The  principal  ones  are  the  upper  and  lower 
maxillae,  the  nasal  and  malar  bones.  The  malar  bones  serve  as  but- 
tresses, and  are  compactly  formed  so  as  to  resist  force  coming  from  that 
side.  Under  conditions  of  emaciation,  when  the  normal  mass  of  fat 
beneath  them  in  the  cheek  disappears,  they  become  very  prominent. 

The  superior  and  inferior  maxillae  serve  principally  as  supports 
for  the  teeth,  and  assist  in  the  mastication  of  food.  The  superior  maxilla 
forms  a  portion  of  the  orbital  and  nasal  cavities,  and  would  be  a  very 
bulky  bone  were  it  not  for  the  large  cavity  which  it  contains,  the  antrum 
of  Highmore  (Fig.  18).  This  latter  is  lined,  like  the  frontal  sinus,  by  a 
mucous  membrane  continuous  with  that  of  the  nose,  and  opens  into 
the  middle  meatus  (see  Figs.  10,  14,  22,  and  26),  close  to  the  orifice  of 
the  frontal  sinus.  Its  opening  is  situated  about  midway  between  its 
floor  and  roof,  so  that  the  conditions  for  drainage  are  poor. 

It  is  frequently  involved,  through  extension  of  infection  from  the  nose 
(empyema  of  antrum),  and  filled  with  a  mucopurulent  secretion.  The 
poor  natural  facility  for  drainage  often  renders  it  necessary  to  drain  the 
antrum  by  other  means.  For  this  purpose  advantage  is  taken  of  the 
fact  that  the  first  molar  tooth  roots  often  project  into  the  floor  of  the 
antrum,  and  the  extraction  of  this  tooth  gives  free  drainage.  The  ante- 
rior wall  of  the  antrum  is  a  very  thin  shell  of  bone,  corresponding  to  a 
ridge  above  the  canine  tooth  (canine  eminence),  and  the  antrum  can  be 
opened  by  lifting  up  the  cheek  and  chiseling  through  this  thin  plate  after 
incising  and  pushing  back  the  periosteum  of  the  upper  maxilla. 

The  malar  bones  and  superior  maxillae  are  rarely  broken,  owing  to 
the  density  and  protection  which  the  former  gives  and  the  rather  deep 
position  of  the  main  portion  of  the  upper  jaw.  There  is  seldom  any 
displacement.  A  fracture  may  vary  from  a  fissure  to  extensive  com- 
minution. 

Fractures  of  the  lower  jaw  are  more  common,  especially  of  its  body. 
They  are  most  frequent  at  or  near  the  median  line  (Gurlt),  due  to  the 


76  THE    HEAD. 

rather  marked  weakening  which  the  mental  foramen  causes.  The 
fracture  is  often  bilateral,  and  if  so,  symmetrical.  Not  infrequently 
the  fracture  communicates,  through  a  tear  in  the  mucous  membrane,  with 
the  cavity  of  the  mouth,  and  thus  becomes  a  compound  fracture.  In- 
fection of  the  fragments  is  scarcely  avoidable,  resulting  in  the  formation 
of  abscesses  which  open  externally  either  over  the  jaw  itself  or  in  the 
submaxillary  region  of  the  neck.  The  alveolar  processes  are  sometimes 
broken  during  the  extraction  of  teeth. 

Tumors  are  often  primary  in  the  jaws,  especially  sarcoma.  Carcin- 
oma of  the  superior  maxillary  often  has  its  starting-point  in  the  mucous 
membrane  of  the  antrum.  Sarcomata  of  the  jaws  grow  very  rapidly, 
owing  to  the  rich  blood-supply,  and  may  become  of  enormous  size. 
Their  removal  usually  involves  a  partial  or  complete  resection. 

Lateral  or  Parotid  Region. 

This  portion  of  the  face  contains  some  very  important  structures, 
whose  relation  to  the  surface  may  be  seen  in  figures  3,  8,  16,  and  17. 

The  region  is  bounded  by  the  ear  behind,  by  the  zygoma  above,  a 
line  drawn  from  the  malar  bone  downward  in  front,  the  lower  border 
of  the  inferior  maxilla,  and  a  line  continued  to  the  mastoid,  below.  The 
skin  covering  it  is  firmer  and  less  elastic  than  that  of  the  anterior  region 
or  face  proper.  The  underlying  muscles  are  not  attached  to  the  skin,  as 
in  the  anterior  region.  The  region  may  be  divided  into  two  layers — 
the  superficial,  including  all  of  the  structures  external  to  the  ramus  of 
the  jaw;  the  deeper,  all  of  those  internal  to  the  same. 

In  the  superficial  layer  lies  the  parotid  gland,  which  is  triangular  in 
shape,  with  base  upward,  the  greater  part  of  it  being  situated  between  the 
condyle  of  the  lower  jaw  and  the  cartilaginous  auditory  canal  (Figs.  3 
and  1 6).  It  contains  within  its  capsule  several  lymphatic  glands  which 
drain  the  anterior  region  of  the  scalp.  The  parotid  gland  is  inclosed 
in  a  firm  fascia  (parotid),  which  is  almost  continuous  except  toward 
its  inner  aspect,  where  it  communicates  with  the  connective  tissue  of 
the  pharynx.  Hence,  parotid  abscesses  are  under  great  tension,  and 
may  rupture  toward  the  pharynx  or  occasionally  into  the  external  audi- 
tory canal.  The  gland  has  passing  through  it  the  facial  nerve,  the  termi- 
nation of  the  external  carotid  artery,  the  beginning  of  the  external 
jugular  vein,  and  the  auriculotemporal  nerve.  The  artery  divides  into 
(see  Figs.  3  and  17)  two  terminal  branches  opposite  the  condyle,  the  in- 
ternal maxillary  and  the  superficial  temporal.  The  facial  nerve  divides, 
inside  the  gland,  into  a  larger  number  of  branches  which  perforate  the 
capsule  on  its  anterior  and  upper  borders,  forming  the  pes  anserinus 


LATERAL  OR  PAROTID  REGION.  77 

(Figs.  8  and  17).  From  about  the  middle  of  the  anterior  border  of  the 
gland  its  duct  (Steno's)  passes  forward  about  a  finger's -breadth  from  the 
zygoma  across  the  masseter  muscle,  to  turn  around  the  anterior  border 
of  this  muscle  and  enter  the  mouth  opposite  the  second  upper  molar 
tooth  (Fig.  17).  The  beginning  of  the  external  jugular  vein  also  lies 
in  the  gland. 

The  fact  that  all  of  these  important  structures  lie  within  the  gland 
renders  it  necessary  to  employ  some  blunt  method  like  that  of  Hilton- 
Roser  in  opening  abscesses.  In  cases  of  operation  for  tubercular  glands 
of  the  neck,  some  of  which  may  be  imbedded  in  the  gland  substance, 
or  in  the  removal  of  tumors  of  the  gland,  these  structures  must  be  borne 
in  mind,  or  a  facial  paralysis  or  salivary  fistula  will  follow. 

In  all  forms  of  inflammation  of  the  gland  the  ear  is  raised  upward 
and  away  from  the  head,  owing  to  its  proximity.  Islands  of  embryonal 
cartilage  from  the  first  or  mandibular  arch  often  remain  inclosed  within 
the  parotid  gland  which  surrounds  the  upper  end  of  the  arch.  In  later 
life  they  may  give  rise  to  the  most  frequent  forms  of  the  tumors  of  the 
parotid,  the  chondromata,  chondrosarcomata,  and  various  forms  of  the 
so-called  mixed  tumors. 

The  epidemic  form  of  parotitis  (mumps)  is  frequently  complicated 
with  a  metastasis  in  the  testis  in  males  (orchitis)  or  in  the  ovary  in 
females  (oophoritis).  This  can  only  be  explained  on  the  theory  of  its 
being  a  general  infection,  and  not  upon  any  anatomic  connection. 

The  only  other  structure  in  the  superficial  layer  is  the  masseter 
muscle,  upon  which  the  parotid  lies  in  part.  It  is  to  be  felt  during 
mastication  as  a  firm  ridge  from  the  zygoma  to  the  lower  border  of  the 
lo\ver  jaw.  It  is  supplied  by  the  motor  root  of  the  fifth  nerve,  and  may 
be  reflexly  contracted  whenever  any  of  the  sensory  branches  of  the 
same  nerve  are  irritated  in  the  mucous  membrane  of  the  mouth  or  the 
teeth.  This  condition  is  called  symptomatic  lockjaw,  and  frequently 
occurs,  especially  in  adults,  during  the  eruption  of  the  third  molar  or 
wisdom  tooth,  in  inflammations  of  the  gums  or  mouth,  and  in  carious 
conditions  of  the  teeth.  A  removal  of  the  cause  disturbing  the  sensory 
or  afferent  branch  of  the  reflex  arc  will  quickly  cause  a  relaxation  of  this 
form  of  reflex  spasm. 

In  tetanus,  formerly  called  idiopathic  lockjaw,  the  contraction  of 
the  masseter  is  an  early  symptom.  The  patient  is  unable  to  open  the 
mouth  on  account  of  the  firm  spasmodic  tonic  contractions  of  the  mas- 
seters  and  pterygoids. 

Between  the  superficial  and  deeper  layers  of  the  parotid  region  lies 
the  ramus  of  the  jaw.  Its  outer  aspect  is  covered  by  the  masseter 


78  THE   HEAD. 

muscle  and  parotid  gland.  Its  coronoid  process  has  attached  to  it  the 
tendon  of  the  temporal  muscle.  Its  condyloid  process  articulates  with 
the  temporal  bone  (temporomaxillary  joint),  whose  relation  to  the  sur- 
face is  shown  in  figure  17.  Its  proximity  to  the  auditory  canal  has 
already  been  mentioned. 

The  force  of  blows  or  falls  upon  the  chin  is  transmitted  through 
this  articulation  (which  is  in  close  relation  to  the  floor  of  the  middle 
fossa)  to  the  skull,  and  may  cause  either  concussion  of  the  brain  or 
fracture  of  the  base  of  the  skull.  The  joint  is  more  frequently  than 
was  formerly  believed  the  seat  of  either  a  simple  (rheumatic)  or  a  sup- 
purative  (pyemic)  synovitis,  the  latter  especially  in  gonorrhea.  The 
pain  is  felt  in  front  of  the  ear  during  movements  of  the  lower  jaw. 
Ankylosis  of  the  joint  following  such  inflammations  may  occur,  neces- 
sitating resection.  Occasionally  the  joint  is  drained  through  an  in- 
cision made  directly  over  it,  care  being  taken  to  avoid  all  the  structures 
lying  in  the  parotid  gland. 

In  the  deep  layer  of  the  parotid  region  lie  the  internal  maxil- 
lary artery,  the  second  and  third  branches  of  the  fifth  nerve,  the  external 
and  internal  pterygoid  muscles,  and,  in  addition,  separated  from  it  by 
the  bones  of  the  middle  fossa,  the  Gasserian  ganglion  of  the  fifth  nerve 
(see  Figs.  8,  15,  and  17).  Their  relation  to  the  surface  may  be  under- 
stood from  a  study  of  figure  17. 

The  external  pterygoid  muscle  is  inserted  close  to  the  condyle  of 
the  jaw.  When  the  mouth  is  opened  widely,  this  muscle  may,  by  its 
sudden  contraction,  pull  the  condyle  across  the  eminentia  articularis, 
and  produce  practically  the  only  variety  of  dislocation  of  the  lower  jaw 
which  occurs — the  forward  or  anterior.  From  this  knowledge  of  the 
mechanism  the  reduction  of  such  a  luxation  is  easy.  The  thumbs 
(well  protected,  so  as  to  avoid  being  cut  with  the  teeth)  are  inserted 
into  the  mouth  and  pressure  made  downward  over  the  lower  molars. 
The  condyle  is  thus  brought  under  the  eminentia  articularis  and 
quickly  slips  past  it  into  the  joint. 

The  chief  branch  of  the  internal  maxillary  artery  which  is  of  clinical 
interest  is  the  middle  meningeal  artery,  which  ascends  to  the  middle 
fossa,  entering  it  through  the  foramen  spinosum  (see  Figs.  6,  9,  10,  and 
12).  The  other  structures  which  for  topographic  purposes  can  be  con- 
sidered in  the  deep  layer  of  the  parotid  region,  are  the  second  and  third 
branches  of  the  trigeminal  nerve  and  the  sphenopalatine  or  Meckel's 
ganglion  (see  Fig.  8).  The  superior  maxillary,  or  second  branch,  passes 
directly  into  the  upper  jaw,  sending  filaments  to  the  teeth  and  forming 
the  infra-orbital  nerve. 

The  inferior  maxillary  divides  into  (Fig.  8) : 


THE    MOUTH,    PHARYNX,    AND    LARYNX.  79 

(a)  The  lingual,  which  passes  on  the  inner  side  of  the  ramus   to 
the  floor  of  the  mouth; 

(b)  The  auriculotemporal  which  penetrates  the  parotid  to  supply 
sensation  to  the  side  of  the  head;  and  into 

(c)  The  inferior  dental,  which  enters  the  inner  side  of  the  ramus 
of  the  jaw  and  supplies  the  lower  teeth  and  ends  in  the  mental  nerve. 
In  the  old  operation  of  Rose,  which  consisted  in  resecting  the  superior 
and  inferior  maxillary  nerves  for  incurable  neuralgia,  these  nerves  were 
resected  shortly  after  their  exit  from  the  skull.     At  the  present  time  this 
operation  has  been  superseded  by  either  the  Krause-Hartley  or  the 
Gushing  operations.     Neuralgia  of  the  branches  of  the  fifth  cranial 
nerve  may  involve  one  or  all  three  principal  nerves  which  arise  from  it. 
The  affection  is  called  " painful  tic"   (tic  douleureux)  or  trigeminal 
neuralgia,  and  the  exits  of  these  three  branches  on  the  face  are  found 
on  pressure  to  be  painful  (see  Anterior  Region  of  Face).     This  may 
become  so  severe  as  to  necessitate  the  removal  of  the  Gasserian  ganglion. 
The  relations  of  the  latter  will  be  understood  by  referring  to  figures  6, 
8,  and  14.     It  can  be  removed  by  a  flap  made  over  the  temporal  region 
(Krause-Hartley),  or  by  resecting  the  zygoma  temporarily  and  chiseling 
nearer  the  base  of  the  skull  (Gushing).     The  latter  has  the  advantage 
of  avoiding  the  middle  meningeal  artery.     In  removing  the  ganglion 
during  this  operation  care  must  be  taken  (see  Fig.  8)  not  to  injure  the 
cavernous  sinus  and  internal  carotid  artery  on  the  inner  side,  and  the 
third,  fourth,  and  sixth  nerves. 

The  Mouth,  Pharynx,  and  Larynx. 

(The  anatomic  and  clinical  relations  of  these  three  important  divi- 
sions of  the  head  to  each  other  and  to  the  nasal  cavity  can  be  under- 
stood by  reference  to  figures  10,  15,  23,  and  24.  At  the  same  time,  it  is 
of  the  utmost  importance  to  examine  one's  own  mouth  and  pharynx 
and  utilize  every  opportunity  in  the  clinic-room  to  make  a  laryngoscopic 
and  posterior  rhinoscopic  examination  of  normal  individuals.) 

The  mouth  can  be  divided  into  two  parts:  The  vestibule,  which  lies 
in  front  of  the  teeth;  and  the  buccal  cavity  proper,  behind  them  (Fig.  24). 

The  vestibule  has  opening  into  it,  opposite  the  second  upper 
molar  tooth,  the  orifice  of  Steno's  duct,  from  which,  by  pulling  the  cheek 
outward,  one  can  see  saliva  discharged  in  spurts,  from  time  to  time. 
In  patients  like  those  suffering  from  typhoid  fever,  who  are  in  such  a 
lethargic  condition  that  food  particles  and  organisms  can  accumulate  in 
the  vestibule,  especially  on  the  gums,  it  can  be  readily  understood  how 
germs  can  travel  upward  along  the  duct  and  cause  a  suppurative  paro- 


80  THE    HEAD. 

titis.  This  complication  is  far  less  frequent  at  present,  since  the  care 
of  the  mouth  has  been  insisted  upon  during  typhoid  fever. 

In  examining  the  vestibule  do  not  neglect  to  palpate  the  upper  and 
lower  reflections  of  the  mucous  membranes  upon  the  jaws,  and  note  the 
outer  surfaces  of  the  latter,  especially  a  depression  above  the  canine 
tooth  eminence,  which  is  the  anterior  wall  of  the  antrum  (Fig.  18).  On 
the  inner  side  of  both  lips  a  number  of  pearly,  minute  elevations  can  be 
seen,  the  buccal  glands,  which  may  become  occluded  and  form  small 
cysts  containing  a  clear  mucus. 

The  teeth  separate  the  vestibule  from  the  mouth  cavity  proper  (see 
Fig.  24).  They  are  inserted  into  excavations  in  the  jaws  called  alveoli, 
which  arc  lined  by  a  periosteum  continuous  with  that  covering  the  re- 
mainder of  the  jaws,  but  much  thinner  and  tougher.  At  the  margin  of  the 
alveolar  cavity  this  periosteum  is  also  continuous  with  the  gums,  as  the 
mucous  membrane  of  the  mouth  covering  the  alveolar  processes  close  to 
the  teeth  is  called.  The  gums  are  firmer  than  the  remainder  of  the  mu- 
cous membrane,  and  help  to  fasten  the  teeth ;  hence,  they  must  be  pushed 
aside  prior  to  the  extraction  of  teeth.  The  gums  are  very  vascular  and 
bleed  readily,  and  are  directly  continuous  with  the  periosteum  of  the 
jaw;  hence,  abscesses  beneath  them  (gum-boils)  are  under  great  tension 
and  are  very  painful.  Foreign  particles  readily  accumulate  at  the  junc- 
tion of  the  gum  and  tooth,  serving  as  pabulum  for  the  many  organisms 
so  constantly  present  in  the  mouth,  and  causing  either  an  inflammation 
of  the  gums  alone  (gingivitis)  cr  of  the  entire  buccal  cavity  (stomatitis). 
Such  conditions  are  especially  frequent  in  marantic,  badly-cared-for 
children,  or,  in  general,  when  care  is  not  taken  to  remove  this  accumu- 
lation frequently.  In  patients  taking  mercury  a  most  violent  stomatitis 
may  occur  as  the  result  of  the  neglect  of  this  detail.  It  is  due,  no  doubt, 
to  the  fact  that  a  small  amount  of  certain  metallic  substances,  like 
lead,  mercury,  and  phosphorus,  are  excreted  through  the  gums  and  are 
deposited  at  their  edges.  This  explains  the  so-called  black  line  at  the 
junction  of  the  gums  and  the  teeth,  in  lead-poisoning,  and  also  the  exten- 
sive destruction  of  the  alveolar  processes  in  phosphorus-necrosis,  caused 
by  the  inhalation  of  phosphorus-fumes. 

The  teeth  are  the  first  temporary  or  milk  teeth,  which  appear 
in  infants  at  the  age  of  seven  months,  and  begin  to  be  replaced  by  the 
second  or  permanent  teeth  at  the  age  of  seven  years.  The  order  of 
eruption  of  these  milk  or  deciduous  teeth  should  be  borne  in  mind: 

The  middle  incisors,  sixth  to  eighth  month. 

Lateral,  eighth  to  twelfth  month. 

First  molars,  twelfth  to  sixteenth  month. 


Fig.  23. — Sagittal  section  of  child's  body  (Rudinger).  i,  Cartilaginous  portion 
of  septum;  behind  it  the  bony  portion  is  seen.  (Vomer  and  rostrum  of  sphenoid.)  2, 
Thyroid  gland,  showing  relatively  large  size  of  same  in  child.  3,  Thymus  gland,  showing 
how  an  enlarged  thymus  may  cause  pressure  upon  the  trachea  and  vessels  at  lower  portion 
of  neck.  4,  Tongue  in  sagittal  section,  showing  how  paralysis  of  muscles  at  base  of  tongue 
will  cause  this  organ  to  fall  back  upon  the  epiglottis  lying  immediately  behind  it  and  thus 
cause  cyanosis  during  anesthesia  by  closure  of  the  glottis.  5,  Nasopharynx.  6,  Liver, 
showing  relations  of  this  organ  to  diaphragm  and  pericardium  above  it,  and  transverse 
colon  and  duodenum  below  it.  7,  Ampulla  of  rectum,  below  which  the  rectum  narrows 
to  form  the  anal  portion  of  the  rectum.  8,  Bladder  and  urethra.  It  will  be  noted  that 
in  the  child  the  greater  portion  of  the  rectum  and  bladder  lie  in  the  abdomen,  the  pelvis 
itself  being  quite  primitive.  Note  also  the  sharp  upward  curve  of  the  urethra. 


81 


^BICUSPID. 

1"  MOLAR, 
-  MOLAR 
^  MOLAR. 


OPENING 
OF  5TENO"5 
DUCT. 


LINE  OF 
INCISION  FO 
PERITOMSILL 
AB6CE65E5. 


LINGUAL  VFIN 


FLOOR  OF  MOUTH 


JUNCTION  OF 
HARD  AND  SOFT 
PALATE5. 

UVULA. 


POSTERIOR 
PILLAR  o^  FAUCES 

FAUCIAL  TONSIL. 


NTERIOR 
ILLA.R  os 
FAUCES 


FRAENUM 
LINGUAE. 


OPENINGS  OF 
6UBMAXILLARY 
AND  5UBLINGUAL 
GLANDS. 


RAN1NE  ARTERY 


Fig.  24. — View  of  adult  mouth  (modified  from  Spalteholz).     M.I.,  Middle  incisor.     L.I., 
Lateral  incisor.     C,  Canine  tooth,     ist  Bic.,  First  bicuspid  tooth. 


THE    MOUTH,    PHARYNX,    AND    LARYNX.  85 

Canine  teeth,  fifteenth  to  twentieth  month. 

Second  molars,  twentieth  to  thirtieth  month. 

The  teeth  of  the  lower  jaw  generally  precede  those  of  the  upper. 

There  are  only  twenty  milk  or  deciduous  teeth,  and  these  are 
gradually  replaced  by  the  permanent  teeth  after  the  age  of  seven  years. 
These  are  thirty-two  in  number,  the  additional  ones  being  the  first  and 
second  bicuspids  and  a  third  molar. 

The  teeth  are  supplied  by  branches  of  the  fifth  nerve,  those  for  the 
upper  jaw  being  derived  from  the  superior  maxillary  branch  of  the  fifth, 
and  those  for  the  lower  jaw  from  the  inferior  dental  branch  of  the 
inferior  maxillary  division  of  the  fifth  (Fig.  8). 

Not  infrequently  carious  teeth,  or  similar  processes  in  the  alveolus, 
are  the  starting-point  of  an  obstinate  neuralgia,  at  first  affecting  only  the 
corresponding  branch  of  the  trigeminal  but  gradually  affecting  all  three 
branches,  so  that  it  is  necessary  to  resect  either  one  of  the  main  trunks 
supplying  the  upper  and  lower  jaws,  or  even  to  resect  the  Gasserian 
ganglion.  If  obstinate  (so-called  tic  douloureux),  a  neuralgic  condition 
of  the  entire  fifth  nerve  exists. 

As  was  stated  before,  infective  inflammations  of  the  gums,  not  infre- 
quently associated  with  the  eruption  of  the  third  or  wisdom  tooth,  may 
give  rise  to  a  spasmodic  contraction  of  the  masseter  muscle,  in  which 
the  sensory  branches  of  the  fifth,  supplying  the  teeth  and  gums,  act  as 
the  afferent,  and  the  motor  root  of  the  fifth  as  the  efferent  side  of  the 
reflex  arc,  the  motor  root  supplying  the  pterygoids  and  masseter  muscle. 
This  spasmodic  contraction  is  often  so  severe  as  to  require  the  actual 
prying  apart  of  the  jaws  in  order  to  gain  access  to  the  wisdom  tooth. 

The  palate  is  divided  into  the  soft  and  hard  palates,  the  latter 
beginning  at  the  posterior  surface  of  the  teeth  and  extending  the  entire 
length  of  the  palatal  processes  of  the  superior  maxillae  and  palate  bones. 
The  mucous  membrane  of  the  palate  is  so  closely  adherent  to  the  peri- 
osteum as  to  form  one  membrane.  This  fact  is  taken  advantage  of  in 
the  repair  of  the  congenital  defect  known  as  cleft  palate.  This  con- 
genital defect  is  similar  in  origin  to  that  of  hare-lip.  In  the  same 
manner  as  was  seen  in  the  case  of  hare-lip,  the  failure  of  the  bony  portions 
of  the  frontonasal  and  superior  maxillary  processes  to  unite  gives  rise  to 
a  gap  along  the  line  which  should  correspond  to  their  point  of  union, 
and  this  gap  is  either  unilateral  or  bilateral.  If  unilateral,  it  is  most 
frequent  on  the  left  side;  if  bilateral,  it  is  very  frequently  associated 
with  an  intermaxillary  bone,  as  in  figure  20,  and  the  two  gaps  or  clefts 
are  separated  by  the  vomer.  In  order  to  repair  this  defect  two  anatomic 
points  are  taken  advantage  of: 


86  THE    HEAD. 

1.  That  the  palate  is  chiefly  nourished   by  the  posterior  palatine 
artery  which  lies  close  to  the  alveolar  processes.     Hence,  to  loosen  the 
flaps  before  suturing  them  the  incision  is  made  parallel  to  the  alveolar 
processes,  so  that  the  artery  is  included  in  the  posterior  end  of  the  flap. 

2.  Knowing  that  the  mucous  membrane  of    the    hard    palate  is 
closely  united  with  the  periosteum,  it  is  stripped  off  or  loosened  from  the 
bone,  except  at  its  anterior  and  posterior  ends,  where  the  corresponding 
palatine  arteries  enter  to  nourish  the  flaps.     The  flaps  from  each  side 
are  then  brought  together  in  the  median  line  and  united.     The  perios- 
teum readily  forms  new  bone  and  the  gap  is  then  bridged. 

The  mucous  membrane  of  the  palate,  both  soft  and  hard,  fre- 
quently shows  changes  during  the  course  of  both  acute  and  chronic 
diseases.  The  eruption  of  measles  can  frequently  be  seen  here,  prior 
to  its  appearance  elsewhere.  Its  deep  injection  in  the  early  stages  of 
scarlatina  is  always  of  diagnostic  value.  Jaundice  often  shows  itself 
near  the  junction  of  the  hard  and  soft  palates  by  a  yellowish  tinge, 
when  but  slightly  marked  in  other  parts  of  the  body.  The  junction 
of  the  soft  and  hard  palate  is  a  frequent  location  for  gummata  in  the 
tertiary  stage  of  syphilis. 

That  portion  of  the  soft  palate  which  hangs  in  the  median  line  is 
called  the  uvula.  It  is  formed  by  the  union  of  four  folds  or  curtains 
of  mucous  membrane,  the  two  in  front  being  called  the  anterior  pillars 
and  those  behind  the  posterior  pillars  of  the  fauces  (see  Figs.  15  and  24). 

The  soft  palate  can  be  raised  and  made  tense  by  two  muscles,  the 
levator  and  tensor  palati  (Fig.  15).  These  muscles  frequently  cause  the 
edges  of  a  cleft  palate  to  be  forcibly  separated,  and  were  formerly  fre- 
quently divided  through  an  incision  half-way  between  the  hamular  pro- 
cess and  Eustachian  tube  and  perpendicular  to  a  line  drawn  between  them. 

Clefts  of  the  soft  palate  may  occur  independently  of  those  of  the 
hard  palate.  At  times  the  soft  palate  or  uvula  may  be  so  elongated  and 
swollen  that  it  hangs  down,  touching  the  epiglottis,  and  at  times  even 
dropping  into  the  entrance  of  the  larynx,  giving  rise  to  severe  attacks  of 
paroxysmal  cough,  whose  nature  cannot  be  understood  until  the  con- 
dition of  the  palate  has  been  thought  of  as  a  cause. 

Between  the  pillars  of  the  fauces  above  spoken  of  are  situated  the 
faucial  tonsils,  as  distinguished  from  the  pharyngeal  or  Luschkifs 
tonsil,  which  will  be  spoken  of  below.  These  tonsils  vary  greatly  in 
size,  and  are  composed  of  lymph-tissue  covered  with  mucous  membrane 
continuous  with  that  of  the  mouth  and  pharynx.  They  contain  a 
considerable  number  of  pocket-like  inversions  of  the  mucous  mem- 
brane, called  follicles,  in  which  debris  frequently  collects;  and  they  are 


THE   MOUTH,    PHARYNX,    AND    LARYNX.  87 

the  seat  of  a  variety  of  inflammation  known  as  follicular  tonsillitis. 
The  tonsils  are  also  a  favorite  location  of  diphtheritic  processes,  this 
disease  causing  an  actual  necrosis  of  the  mucosa.  At  times  in  follicular 
tonsillitis,  the  organisms  may  migrate  through  the  mucous  membrane 
into  the  submucous  tissue,  and  give  rise  to  a  peritonsillar  abscess,  or 
quinsy.  Such  an  inflammation  will  cause  extensive  edema  of  the 
loose  connective  tissue  of  the  soft  palate  and  pillars  of  the  fauces,  and 
may  even  extend,  unless  relieved  by  incision,  to  the  submucous  tissue 
of  the  glottis  as  far  as  the  vocal  cords,  causing  an  edema  of  the  glottis, 
and,  in  some  cases,  asphyxiation  as  a  result  of  the  latter. 

The  tonsil  is  supplied  by  a  branch  of  the  ascending  palatine  artery, 
and  at  times  by  a  branch  of  the  facial  artery.  As  will  be  seen  in  the 
section  on  the  submaxillary  region  of  the  neck  the  facial  artery  may  at 
times  dip  in  so  deeply  as  to  be  caught  tangentially  by  the  tonsillotome, 
and  severe  hemorrhage  result.  The  internal  carotid  artery  lies  a  suffi- 
ciently great  distance  from  the  tonsil  to  be  ignored  as  a  source  of  severe 
hemorrhage  after  tonsillotomy.  The  least  dangerous  place  to  open  the 
abscess  of  the  peritonsillar  tissues  is  by  an  incision  made  parallel  to  the 
anterior  pillar  of  the  fauces  (see  Fig.  24). 

The  space  between  the  pillars  of  the  fauces  on  each  side  is  known 
as  the  isthmus  of  the  fauces.  At  times  the  tonsils  may  be  so  hyper- 
trophied  and  swollen  as  to  almost  meet  each  other  in  the  median  line, 
entirely  filling  the  isthmus. 

On  the  floor  of  the  mouth,  to  each  side  of  the  median  line,  corre- 
sponding to  two  fringes  of  mucous  membrane  which  meet  at  the  tip  of 
the  tongue,  are  the  ranine  arteries  (see  Fig.  24).  In  the  median  line  at 
the  junction  of  the  tongue  with  the  floor  of  the  mouth  are  two  papillae 
which  correspond  to  the  openings  of  the  ducts  of  Wharton;  a  little  more 
externally  is  the  orifice  for  the  duct  of  the  sublingual  gland.  Passing 
from  the  floor  of  the  mouth  to  the  under  surface  of  the  tongue  is  a  whitish 
fibrous  band  in  the  median  line,  known  as  the  frenum  of  the  tongue. 
In  infants  this  is  at  times  exceedingly  short  (tongue-tied),  and  must  be 
cut.  Great  care  must  be  taken  to  lift  the  tongue  upward  in  order  not 
to  wound  the  ranine  artery.  The  best  method  of  doing  this  is  to  place 
the  frenum  in  the  notch  at  the  broad  end  of  a  grooved  director  and  hold 
the  latter  against  the  tongue,  dividing  the  frenum  below  it.  The  base 
of  the  tongue  at  the  junction  with  the  floor  of  the  mouth  is  a  frequent 
seat  of  dermoid  cysts  and  also  of  a  benign  tumor  known  as  ranula,  due 
to  obstruction  of  the  ducts  of  the  sublingual  and  submaxillary  glands. 
A  little  more  externally,  opposite  the  molar  teeth,  just  beneath  the 
mucous  membrane,  lies  the  lingual  nerve  (see  Figs.  8  and  10). 
6 


88  THE    HEAD. 

The  tongue,  for  practical  purposes,  can  be  considered  as  a  solid 
muscular  organ,  although  it  is  composed  of  two  sets  of  muscles:  (i)  The 
extrinsic,  such  as  the  hyoglossus  and  styloglossus,  which  pull  the  tongue 
back,  and  the  genioglossus,  which  pulls  the  tongue  forward;  and  (2)  the 
intrinsic  muscle,  or  lingualis,  which  causes  change  in  the  contour  of  the 
tongue. 

These  muscles  are  all  supplied  by  the  hypoglossal  and  chorda 
tympani  nerves.  The  mucous  membrane  covering  the  tongue  is  very 
thin  on  its  inferior  aspect,  but  much  thicker  on  the  upper  surface. 
Scattered  all  over  the  dorsum  are  a  number  of  fine  filiform  papillae. 
Between  these,  along  the  edge  of  the  tongue,  are  the  fungiform,  which 
are  enlarged  in  scarlet  fever,  giving  rise  to  the  strawberry  tongue  of  that 
disease,  which,  appears  about  the  third  or  fourth  day;  and  at  the  root  of 
the  tongue,  which  is  the  portion  nearest  the  larynx,  there  is  a  row  of  large 
papillae  on  each  side,  known  as  the  circumvallate  papillae  (see  Fig.  15). 

There  are  many  mucous  glands  over  the  tongue,  especially  at  its 
base  or  root,  and  at  the  tip  on  each  side  of  the  frenum.  The  collection 
of  adenoid  tissue  at  its  base,  just  behind  the  circumvallate  papillae,  is 
called  the  lingual  tonsil.  Its  enlargement  may  be  a  frequent  cause  of 
irritating  cough  (see  Fig.  15). 

The  mucous  membrane  of  the  tongue,  as  well  as  that  of  the  mouth, 
is  the  seat  of  a  disease  known  as  psoriasis,  which  shows  itself  by  whitish 
plaques.  When  the  muscles  of  the  tongue  are  paralyzed  or  lose  their 
support  (for  example,  after  the  resection  of  the  lower  jaw),  the  tongue 
may  fall  backward  and  obstruct  the  entry  of  air  into  the  larynx.  When 
this  happens  in  chloroform  anesthesia,  the  tip  of  the  tongue  must 
be  brought  forward  with  a  special  forceps;  or  the  same  can  be  accom- 
plished by  lifting  the  jaw  up  and  forward  by  grasping  it  at  its  angle. 

The  tongue  receives  its  blood-supply  from  the  lingual  artery. 
Wounds  of  this  organ  bleed  readily,  but  the  hemorrhage  is  easily  checked 
by  transfixion.  The  lingual  vein  accompanies  the  artery  throughout 
its  course,  and  the  radicles  of  this  vein  are  especially  numerous  along 
the  inferior  surface.  The  tongue  is  exceedingly  richly  supplied  with 
lymph-vessels,  draining  into  the  submaxillary  and  deep  cervical  glands; 
hence,  the  spread  of  carcinoma  is  favored. 

Infection  of  the  tongue,  or  glossitis,  causes  great  swelling  of  the 
organ,  on  account  of  the  large  amount  of  connective  tissue  between  the 
muscles.  The  sensory  nerves  of  -the  tongue  are  the  lingual,  which 
supplies  it  with  general  sensation,  and  the  glossopharyngeal,  which 
supplies  it  with  the  sense  of  taste.  Macroglossia  is  the  name  given  to  a 
large  tongue,  due  to  the  presence  of  a  lymphangioma.  The  under  sur- 


THE    MOUTH,    PHARYNX,    AND    LARYNX.  89 

face  of  the  tongue,  as  well  as  the  inner  surface  of  the  cheeks  and  the 
pillars  of  the  fauces,  may  be  the  seat  of  a  cavernous  hemangioma. 

The  Pharynx  (see  Figs.  10,  15,  and  23). — The  pharynx  has  as  its 
roof  or  vault  the  under  surface  of  the  body  of  the  sphenoid  and  part  of 
the  basilar  process  of  the  occipital  bone ;  as  its  posterior  wall,  the  anterior 
surfaces  of  the  cervical  vertebrae  from  the  second  to  the  sixth. 

On  its  anterior  wall  is  the  orifice  of  communication  with  the  nose 
and  mouth  (Fig.  24) ;  on  its  lateral  wall,  the  soft  parts  over  the  in- 
ternal carotid  artery,  and  ninth,  tenth,  and  twelfth  nerves,  and  the 
orifice  of  the  Eustachian  tube. 

Its  lower  portion  is  formed  by  the  larynx  and  by  the  beginning  of  the 
esophagus  (Fig.  15).  It  is  about  five  inches  in  length;  the  distance  from 
the  arch  of  the  teeth  to  the  beginning  of  the  esophagus  is  about  six  inches, 
and  a  finger  introduced  into  the  mouth  can  touch  the  second,  third,  fourth, 
fifth,  and  sixth  cervical  vertebrae.  The  pharynx  is  lined  throughout  by 
mucous  membrane,  which  is  continuous  with  that  of  the  nose  and  mouth. 
Its  curved  roof  or  vault  and  posterior  wall  are  frequently  the  seat  of  lym- 
phoid  tissue,  which  enlarges  considerably  under  certain  conditions,  form- 
ing an  obstruction  to  the  posterior  nares,  and  requiring  removal  by  a 
special  instrument.  The  relation  of  this  lymphoid  tissue  or  adenoid  vege- 
tation to  the  orifice  of  the  Eustachian  tube  on  the  lateral  wall  of  the 
pharynx  causes  it  to  assume  considerable  importance  in  the  etiology  of 
deafness  (see  Figs.  10  and  14).  Patients  who  have  such  enlarged  pharyn- 
geal  tonsils  can  breathe  but  little  through  the  nose,  giving  rise  to  a  lack 
of  development  of  the  upper  half  of  the  face  in  children,  and  an  increase 
in  the  arching  of  the  vault  of  the  palate.  On  the  lateral  wall  of  that 
portion  of  the  pharynx  known  as  the  nasopharynx,  which  lies  above 
the  soft  palate,  is  seen  the  orifice  for  the  Eustachian  tube  (see  Fig. 
10).  On  the  anterior  wall  are  seen  the  two  posterior  nares  and  the 
posterior  ends  of  the  three  turbinate  bones.  At  its  lower  end  (the 
junction  with  the  esophagus,  about  opposite  the  cricoid  cartilage)  is  a 
favorite  place  for  foreign  bodies  to  lodge  (Figs.  10,  15,  and  23).  On 
the  posterior  wall  there  is  a  lymph-gland  situated  in  the  median  line, 
which  frequently  breaks  down,  forming  a  retropharyngeal  abscess  in 
children,  which  can  be  felt  as  a  bulging  on  the  posterior  wall  of  the 
pharynx  when  the  finger  is  introduced  into  the  mouth.  Such  a  retro- 
pharyngeal abscess,  as  it  is  called,  may  be  formed  as  a  result  of  tuber- 
culosis of  the  cervical  vertebrae,  and  should  not  be  opened  through  the 
mouth  if  possible,  but  by  an  incision  made  along  the  anterior  border  of 
the  sternocleidomastoid,  opposite  the  angle  of  the  jaw.  The  retro- 
pharyngeal connective  tissue  is  continuous  with  that  of  the  posterior 


90  THE    HEAD. 

mediastinum;  hence,  abscesses  are  exceedingly  liable  to  gravitate  to 
the  latter  (see  Neck;  also  Fig.  31). 

The  Nose. 

The  nose  may  be  described  as  consisting  of  an  external  and  an  inter- 
nal portion.  The  former  forms  part  of  the  face,  and  the  description  of 
its  examination  in  the  living  appears  in  the  section  on  the  face.  Its 
upper  boundary  is  formed  by  a  slight  depression  below  the  glabella  (root 
of  nose).  Its  lower  boundary  is  at  its  junction  with  the  upper  lip,  while 
its  lateral  boundaries,  poorly  marked  above,  are  formed  by  the  alae  or 
wings  of  the  nose  below.  The  skin  of  the  nose  is  not  very  elastic  and 
is  adherent  to  the  alar  cartilages  below.  It  is  not  as  richly  supplied 
with  blood-vessels  as  the  remainder  of  the  face;  hence,  it  is  poorly 
adapted  for  plastic  operations,  and  wounds  do  not  heal  as  readily. 

In  those  exposed  to  the  weather,  in  alcoholics,  and  in  some  dis- 
turbances of  the  digestive  tract  of  a  chronic  nature,  the  superficial 
vessels  become  dilated  and  remain  so  permanently.  The  large  seba- 
ceous glands,  especially  in  the  fold  between  the  alae  and  cheeks,  predis- 
pose it  to  many  of  the  diseases  of  these  glands — acne,  etc.  The 
skin  is  not  infrequently  the  seat  of  a  slow-growing  form  of  epithelioma 
(ulcus  rodens)  in  the  aged  and  of  syphilitic  lesions.  Lupus  vulgaris  often 
affects  the  alae.  The  only  muscles  are  those  which  widen  and  narrow 
the  nostrils;  they  are  supplied  by  the  seventh  nerve.  In  addition  to 
their  function  as  muscles  of  expression  they  serve  as  accessory  muscles 
of  respiration,  especially  the  dilators,  and  their  involuntary  employment 
takes  place  in  all  cases  of  dyspnea. 

In  children  with  bronchopneumonia  or  laryngeal  stenosis  the  in- 
spiratory  dilatation  of  the  nostrils  is  quite  characteristic.  The  bony 
and  cartilaginous  support  of  the  skin  of  the  external  nose  is  formed 
by  (see  Fig.  18)  the  two  nasal  bones  and  two  lateral  cartilages  distal 
to  them.  The  nasal  bones  rest  upon  the  frontal  bone  above  and  the 
superior  maxillae  on  each  side,  and  upon  the  septum  (bony  and  carti- 
laginous) in  the  median  line.  They  extend  down  to  the  level  of  the 
inner  canthus  of  the  eye;  beyond  that  point  the  external  nose  is  carti- 
laginous. 

Distal  to  the  two  lateral  cartilages  are  two  curved  cartilages  (alar) 
which  give  shape  to  the  wing  of  the  nose  (see  Fig.  18).  A  deformity 
of  the  external  nose,  commonly  observed  as  the  result  of  syphilis  or 
of  a  chronic  rhinitis,  is  called  saddle-nose  (see  Fig.  25).  It  will  be 
referred  to  later. 

The  blood-supply  of  the  external  nose  is  received  from   the  facial 


Fig.  25. — Saddle-nose.     Due  to  necrosis  of  cartilaginous  portion  of  septum. 


Fig.  26. — Coronal  section  to  show  ethmoidal  cells  and  antra  of  Highmore.  Seen 
from  behind,  i,  Fat  and  cellular  tissues  surrounding  globus  of  the  eye.  2,  Anterior 
fossa  of  skull,  showing  crista  galli.  3,  Superior  turbinated  bone.  4,  Middle  turbinated 
bone.  5,  Inferior  turbinated  bone.  6,  Deviation  of  septum  to  right.  7,  Hard  palate. 
8,  Posterior  end  of  left  frontal  sinus.  9,  Ethmoidal  cells,  showing  their  close  relation  to 
the  orbit.  The  sound  (white  line)  in  No.  8  indicates  the  direction  of  its  opening.  When 
followed  down  upon  the  left  side  of  the  illustration,  it  can  be  seen  in  the  middle  meatus, 
close  to  the  opening  of  the  antrum  of  Highmore  (10),  similarly  indicated  by  a  probe  (white 
line)  on  both  sides. 


THE   NOSE.  93 

artery,  and  its  veins  empty  into  the  facial  vein,  and  by  some  radicles  of 
the  ophthalmic  vein  into  the  cavernous  sinus.  This  latter  communica- 
tion between  the  veins  of  the  exterior  and  those  of  the  interior  of  the 
skull  has  been  referred  to  above  as  being  of  great  importance  in  cases  of 
infection.  The  nasal  lymphatics  drain  into  the  submaxillary  deep  cer- 
vical glands. 

The  internal  nose  serves  two  purposes.  In  its  uppermost  portion 
(sides  of  bony  septum  and  over  ethmoid  bone)  it  contains  the  terminal 
filaments  of  the  olfactory  nerve.  Its  lower  portion  serves  to  warm  the 
inspired  air  as  it  passes  to  the  lungs.  It  has,  opening  into  its  lateral 
walls,  the  lachrymal  duct  which  conveys  the  tears  from  the  eye  (Fig.  10), 
and  also  a  number  of  pneumatic  cavities,  or  accessory  sinuses,  situated 
in  the  bones  of  the  face  and  skull.  The  exact  function  of  these  acces- 
sory sinuses  is  not  clear.  They,  like  the  mastoid  cells,  are  scarcely  devel- 
oped in  infants.  In  their  development  they  probably  aid  through  giving 
the  facial  bones  an  opportunity  to  grow  without  increasing  their  bulk. 
If  a  nasal  speculum  is  inserted  into  the  nostrils  (anterior  nares),  one 
notes  first  that  for  a  distance  of  one-half  of  an  inch  the  skin  of  the 
face  lines  the  external  openings  of,  the  nose  and  has  many  hairs, 
called  "vibrissze."  They  serve  to  obstruct  dust  particles,  and  at  times 
the  sebaceous  glands  supplying  them  become  inflamed,  giving  rise  to 
little  furuncles  which  cause  considerable  swelling  and  severe  pain  in  the 
face.  One  can  see  upon  the  lateral  walls  the  anterior  ends  of  the  middle 
and  inferior  turbinated  bones  covered  by  reddish  mucous  membrane. 
The  septum  is  composed  of  a  cartilaginous,  or  anterior,  and  a  bony,  or 
posterior,  portion  (see  Fig.  23).  The  cartilaginous  portion  is  formed  by  a 
quadrangular  cartilage  which  assists  in  supporting  the  external  nose.  The 
bony  septum  is  formed  by  the  perpendicular  plate  of  the  ethmoid  and  the 
rostrum  of  the  sphenoid  above  and  the  vomer  below.  The  septum 
divides  the  nose  into  two  lateral  halves  which  are  perfectly  similar  in 
function  and  structure. 

Deviations  of  the  septum  are  present  in  the  majority  of  adults  (240 
in  370,  Zuckerkandl).  Most  frequent  is  the  bending  to  the  right, 
affecting  almost  always  the  anterior  two-thirds  of  the  septum  (see  Fig. 
26).  This  deviation  is  probably  due  to  the  fact  that  the  septum  grows 
more  rapidly  than  the  surrounding  bony  structures,  and  is  bent  either 
in  a  circumscribed  or  a  diffuse  manner. 

On  the  lateral  walls  of  each  half  of  the  nose  are  three  ridges  pro- 
jecting into  its  lumen,  covered  with  mucous  membrane  (see  Figs.  10,  22, 
and  26).  They  are  the  turbinated  bones,  the  two  upper  (superior  and 
middle)  being  a  part  of  the  ethmoid  bone  and  the  lowest  (inferior)  a. 


94  THE    HEAD. 

separate  bone.  The  spaces  between  them  are  called  meati,  and  have 
opening  into  them  the  lachrymal  duct  into  the  inferior;  the  orifices  of 
the  antrum  of  Highmore,  frontal  sinus  and  anterior  ethmoidal  cells  into 
the  middle  meatus;  and  the  orifices  of  the  sphenoidal  and  posterior 
ethmoidal  cells  into  the  superior  meatus  (see  Figs.  10,  22,  and  26).  The 
entire  internal  nose  is  lined  with  a  mucous  membrane  which  is  con- 
tinuous with  that  of  the  pharynx  and  that  lining  the  accessory  cavities. 
For  this  reason,  inflammation  may  extend  by  continuity  into  either  the 
accessory  sinuses  or  into  the  pharynx,  and  from  the  latter  into  the  middle 
ear  (see  Ear)  through  the  Eustachian  tube.  The  orifices  of  the  sinuses 
are  so  small  and  so  poorly  situated  (see  Figs.  22  and  26)  for  drainage  that 
when  once  infected  the  mucopurulent  secretion  can  be  easily  retained. 

The  orifices  may  be  entirely  closed  up  by  the  swollen  condition  of 
the  mucous  membrane,  and  an  empyema  or  collection  of  pus  in  a  sinus 
(sinusitis)  result.  On  account  of  the  rigid  bony  wall,  the  pain  may  be 
quite  intense,  referred  to  the  supra-orbital  region  in  a  case  of  frontal 
sinusitis,  to  the  forehead  in  the  median  line  in  ethmoiditis,  or  over  the 
upper  jaw  or  molar  teeth,  for  empyema  of  the  antrum  (Fig.  18). 

Cases  of  frontal  sinusitis  have  been  treated  for  supra-orbital  neu- 
ralgia, on  account  of  the  proximity  and  accompanying  involvement  of  the 
nerve.  There  is  frequently  a  communication  between  the  frontal  sinus 
and  anterior  ethmoidal  cells  (see  Fig.  22)  which  may  explain  the  ob- 
stinacy of  cases  of  infection  of  the  former.  It  is  exceedingly  difficult 
to  open  the  orifices  of  these  sinuses  through  the  nose,  especially  the 
frontal  and  antrum,  and  practically  impossible  in  the  case  of  the  eth- 
moidal and  sphenoidal  sinuses,  so  that  they  must  generally  be  opened 
through  their  walls,  the  antrum  either  through  its  floor  (tooth  extrac- 
tion) or  anterior  wall,  the  frontal  and  ethmoidal  by  external  incisions 
and  chiseling  (see  Fig.  18)  and  the  sphenoidal  through  the  nose. 

The  mucous  membrane  covering  the  free  edge  and  upper  surface 
of  the  turbinated  bones,  as  well  as  that  of  the  corresponding  portions  of 
the  septum,  is  an  erectile  tissue  which  swells  to  such  an  extent  under 
certain  nervous  and  infectious  conditions  that  the  entire  lumen  is 
obstructed.  This  condition  is  present  in  hay-fever,  and  in  acute  and 
chronic  rhinitis.  The  blood-supply  of  the  nose  is  derived  from  the 
internal  maxillary  (sphenopalatine)  artery,  which  enters  it  from  the 
posterior  half.  Nasal  hemorrhage  (epistaxis)  is  rarely  severe,  especially 
if  from  the  anterior  half  of  the  nose,  which  has  the  smallest  vessels.  It 
usually  ceases  after  tamponing  the  anterior  nares.  Occasionally  the 
hemorrhage  may  be  so  severe  as  to  require  tamponade  of  the  opening 
of  the  nose  into  the  pharynx  (see  Fig.  21). 


THE   ORBIT   AND   EYE.  95 

The  veins  of  the  upper  portion  of  the  nose  empty  into  those  of 
the  dura,  those  of  the  lower  portion  into  the  veins  of  the  pharynx  and 
face.  The  lymphatics  empty  into  a  gland  in  front  of  the  second  cer- 
vical vertebrae  and  into  the  deep  cervical  glands.  The  first-named 
relation  of  the  lymphatics  may  explain  the  frequency  of  retro- 
pharyngeal  abscess  in  infants,  secondary  to  rhinitis.  There  is  also 
communication  between  the  lymphatics  of  the  nose  and  the  subarach- 
noid  space.  This  is  the  reason  why  a  septic  meningitis  at  times  com- 
plicates empyema  of  the  upper  air-cells  (ethmoidal).  The  anatomic 
fact  that  the  deep  cervical  glands  drain  the  lower  portion  of  the  nose 
explains  their  frequent  secondary  involvement  (tubercular  lymphaden- 
itis) when  the  primary  atrium  of  infection  has  been  in  the  nose.  Syphilis 
or  atrophic  rhinitis  may  give  rise  to  necrosis  of  either  the  bony  or 
cartilaginous  portion  of  the  septum,  causing  the  roof  or  external  nose  to 
fall  in,  giving  rise  to  the  deformity  known  as  saddle-nose  (Fig.  25). 

Fractures  of  the  external  nose  usually  involve  the  nasal  bones,  but 
more  frequently  there  is  a  separation  from  their  attachments  to  the 
frontal  and  superior  maxillae  and  to  the  quadrilateral  cartilages.  The 
latter  are  often  bent  inward  by  a  trauma.  Deviations  of  the  septum  at 
times  follow  an  injury.  A  fracture  of  the  nose  may  extend  through 
the  ethmoid  (which  forms  the  roof  of  the  nose)  into  the  anterior  fossa 
of  the  skull.  The  lachrymal  duct  may  be  obstructed  as  the  result  of  a 
fracture.  A  fracture  involving  the  frontal  sinuses  may  cause  escape  of 
air  into  the  skin  (emphysema). 

The  Orbit  and  Eye. 

The  Orbit. — The  orbits  or  sockets  for  the  eye  consist  of  two  pyr- 
amidal-shaped cavities,  with  their  apices  behind.  The  axes,  if  prolonged, 
would  pass  through  the  optic  foramina,  and  meet  behind  the  pituitary 
fossa  of  the  sphenoid.  Each  orbit  is  composed  of  the  frontal,  sphenoid, 
ethmoid,  malar,  lachrymal,  palate,  and  superior  maxillary  bones. 

The  bones  forming  the  roof,  floor,  and  inner  wall  of  the  orbit  are  very 
thin,  and  consequently  in  close  connection  with  the  nasal  fossae,  the 
ethmoidal,  sphenoidal,  frontal  sinuses,  and  the  antrum  of  Highmore, 
so  that  foreign  bodies  thrust  into  the  orbit  might  easily  penetrate  these 
structures,  or,  vice  versa,  tumors  may  readily  invade  the  orbit  by  de- 
stroying the  thin  bony  wall  intervening  between  these  cavities  (Figs.  22 
and  26). 

The  apex  or  posterior  portion  of  the  orbit  presents  (i)  the  optic 
foramen  for  the  transmission  of  the  optic  nerve  and  the  ophthalmic 
artery;  (2)  the  sphenoidal  fissure  through  which  passes  the  ophthalmic 


g6  THE   HEAD. 

nerve,  the  first  branch  of  the  trigeminus,  and  the  nerves  supplying  the 
muscles  of  the  eye;  (3)  the  sphenomaxillary  fissure  transmitting  the 
second  branch  of  the  trigeminus. 

At  the  upper  inner  angle  of  the  superior  border  of  the  orbit  is  found 
the  supra-orbital  notch,  for  the  transmission  of  the  supra-orbital  nerve 
and  artery;  while  below,  on  the  inferior  border,  the  infra-orbital  nerve 
and  artery  emerge  through  the  infra-orbital  foramen  (see  Fig.  3). 

The  orbital  nerves  may  be  injured  in  wounds  or  fractures  involving 
the  orbit,  or  be  pressed  upon  by  tumors  or  bony  exostoses  from  various 
parts. 

The  orbit  contains  the  eyeball,  with  its  attached  muscles,  the  optic 
nerve,  lachrymal  gland,  blood-vessels,  nerves,  fat,  and  fasciae. 

The  bony  wall  of  the  orbit  is  covered  by  periosteum.  Immediately 
beneath  it,  forming  a  loose  delicate  sheath  for  the  muscles,  is  the  orbital 
fascia,  containing  a  larger  quantity  of  loose  fatty  cellular  tissue.  It  is 
by  the  absorption  of  this  fat  in  extreme  emaciation  and  in  the  aged  that 
recession  of  the  eyeball  or  enophthalmus  is  produced.  Owing  to  its 
loose  structure,  it  affords  easy  means  for  the  spread  of  orbital  suppura- 
tion. In  Basedow's  disease,  or  exophthalmic  goiter,  one  of  the  chief 
symptoms  is  the  protrusion  of  the  eyeball  (exophthalmus). 

Surrounding  the  globe  from  near  the  margin  of  the  cornea  to  the 
entrance  of  the  optic  nerve  is  Tenon's  capsule.  This  investment  con- 
sists of  a  visceral  and  a  parietal  layer.  The  parietal  layer  clothes  the 
fatty  tissue  surrounding  the  globe,  and  the  visceral  layer  covers  the 
posterior  part  of  the  eyeball  from  the  margin  of  the  cornea  to  the  entrance 
of  the  optic  nerve.  As  the  tendons  of  the  ocular  muscle  pierce  Tenon's 
capsule,  the  latter  gives  off  some  fibers,  which  aie  reflected  upon  them, 
thus  reinforcing  the  sheaths  of  the  muscles. 

The  blood -supply  of  the  orbit  is  derived  from  the  ophthalmic  artery, 
Traumatism  of  the  orbit  may  produce  pulsating  tumors  of  one  of  the 
orbital  arteries. 

To  the  eyeball  are  attached  six  muscles:  the  four  recti — external, 
internal,  superior,  and  inferior — and  the  two  oblique — superior  and 
inferior  (see  Fig.  26).  The  four  recti  take  their  origin  about  the  optic 
foramen,  and  are  inserted  into  the  sclera  by  a  tendinous  expansion, 
about  ten  millimeters  wide.  Their  insertion  is  not  equidistant  from 
the  sclerocorneal  junction,  but  varies.  The  internal  rectus  is  about 
6.5  millimeters  from  the  limbus  corneae;  the  external  rectus,  7  milli- 
meters; the  superior  rectus,  8  millimeters;  and  the  inferior  rectus,  7.5 
millimeters.  The  tendon  of  the  external  or  internal  rectus  muscles  is 
frequently  divided  in  cases  of  strabismus. 


THE    ORBIT   AND    EYE.  97 

The  Globe. — The  cornea  forms  the  clear,  transparent,  anterior  part 
of  the  fibrous  coat  of  the  eye.  It  is  slightly  elliptic  in  shape,  with  the 
major  axis  in  the  horizontal  meridian.  The  cornea  is  composed  of 
five  layers,  the  greater  part  of  which  consists  of  a  large  number  of 
bundles  of  connective-tissue  fibers  (lamellae),  between  which  are  anasto- 
mosing cell-spaces  containing  the  corneal  corpuscles.  It  is  along  these 
cell-spaces  that  suppuration  takes  place.  Except  at  the  limbus  the 
cornea  contains  no  blood-vessels,  but  it  is  richly  supplied  with  nerves 
derived  from  the  ciliary  plexus,  formed  by  the  long  and  short  ciliary 
nerves. 

The  sclera,  together  with  the  cornea,  form  the  external  fibrous  coat 
of  the  eye.  It  is  thickest  at  its  posterior  part,  where  it  measures  about 
one  millimeter  in  thickness.  Anteriorly  it  is  pierced  by  a  number  of 
minute  openings  through  which  the  anterior  ciliary  arteries  and  veins 
pass.  Posteriorly  it  is  pierced  by  the  optic  nerve. 

The  choroid  forms  the  dark  coating  of  the  eye,  and  is  the  vascular 
tissue  of  the  globe  supplying  nutrition  to  the  vitreous,  retina,  and  lens. 
In  injuries  to  the  globe  excessive  hemorrhage  may  take  place  from  this 
structure. 

The  retina  is  a  thin  transparent  membrane,  placed  between  the 
hyaloid  membrane  of  the  vitreous  within  and  the  choroid  externally. 
Its  attachment  to  the  choroid  is  so  delicate  that  it  may  be  detached  by 
traumatism,  hemorrhage,  or  effusions.  The  optic  nerve  pierces  the 
posterior  pole  of  the  eye  about  three  millimeters  to  its  inner  side,  at  a 
spot  known  as  the  papilla  or  disc. 

The  aqueous  chamber  is  bounded  anteriorly  by  the  cornea,  poste- 
riorly by  the  capsule  and  suspensory  ligament  of  the  lens.  This  space 
is  again  divided  by  the  iris  into  the  anterior  and  posterior  chambers, 
collecting  the  lymph  of  the  anterior  portion  of  the  eye,  known  as  the 
aqueous  humor.  Any  cause  tending  to  interfere  with  the  normal  circu- 
lation of  fluid  from  the  vitreous  through  to  the  posterior  and  anterior 
chambers  produces  an  increase  of  intraocular  tension  of  the  globe;  a 
condition  known  as  glaucoma. 

The  vitreous  is  a  transparent  colorless  mass  filling  the  posterior 
cavity  of  the  globe,  depending  for  its  nutrition  upon  the  surrounding 
structures,  which,  when  diseased,  usually  affect  the  vitreous. 

The  iris  is  the  colored  membranous  diaphragm  immediately  in  front 
of  the  lens,  containing  a  central  opening,  the  pupil.  It  extends  from  the 
ciliary  body  over  the  lens,  while  its  central  or  pupillary  border  lies  upon 
the  anterior  capsule  of  the  lens.  The  vessels  of  the  iris  and  choroid  are 
so  closely  related  that  inflammations  set  up  in  the  iris  very  easily  spread 


98  THE    HEAD. 

to  the  choroid.  When  the  iris  is  inflamed,  its  color  is  altered,  due  to 
congestion  and  exudation  into  its  substance.  After  iritis,  therefore, 
it  is  not  uncommon  to  find  the  posterior  surface  of  the  iris  adherent  to 
the  anterior  capsule  of  the  lens  (posterior  synechiae). 

The  ciliary  body  is  a  circular  organ,  extending  from  the  base  of  the 
iris  to  the  anterior  part  of  the  choroid.  It  consists  of  the  ciliary  muscle 
and  processes.  Wounds  involving  this  region  assume  grave  characters, 
owing  to  the  other  structures  usually  affected.  If  the  ciliary  body  be 
injured,  the  sclera,  choroid,  retina,  vitreous,  conjunctiva,  and  iris  may 
all  be  involved. 

The  lens  is  a  biconvex  transparent  body,  inclosed  in  a  capsule  and 
held  in  position  by  its  suspensory  ligament.  It  separates  the  vitreous 
chamber  behind  from  the  aqueous  chamber  in  front.  It  is  composed  of 
a  central  portion,  the  nucleus,  and  a  softer  peripheral  portion,  known 
as  the  cortex.  In  the  various  forms  of  cataract,  the  whole  lens  or  some 
portion  of  it  or  of  its  capsule  becomes  the  seat  of  the  opacity. 

The  conjunctiva  is  a  delicate  thin  mucous  membrane  covering  the 
posterior  surface  of  the  eyelids,  and  is  reflected  on  to  the  anterior  surface 
of  the  globe,  forming  the  conjunctival  sac.  It  is  divided  into  the  palpe- 
bral,  that  covering  the  posterior  portion  of  the  lid;  the  ocular  or  bulbar, 
covering  the  anterior  part  of  the  globe;  and  the  fornix  or  transition  fold, 
that  portion  between  the  lid  and  globe.  The  part  of  the  palpebral 
portion  that  covers  the  tarsus  is  known  as  the  tarsal  conjunctiva. 

The  eyelids  are  two  movable  folds  of  skin,  covering  the  eyeball, 
which  by  their  attachments  close  in  the  orbital  cavity.  The  outer 
margins  of  the  lids  unite  to  form  the  external  canthus.  At  the  inner 
margin,  the  internal  canthus,  a  small  red  elevation  is  found,  known 
as  the  caruncle  (see  Fig.  18).  The  following  layers  are  found  from 
before  backward:  The  skin,  loose  connective  tissue,  muscular  tissue, 
tarsal  cartilage  and  fascia,  and  conjunctiva.  The  lids  owe  their  stiff- 
ness to  the  tarsal  cartilages.  The  margins  of  the  lids  are  fringed  with 
short  hairs  or  cilia.  On  everting  the  lid,  the  openings  of  the  Meibo- 
mian  glands  are  seen. 

The  lachrymal  apparatus  consists  of  the  lachrymal  gland  or  secre- 
tory portion  and  the  lachrymal  passages. 

The  lachrymal  gland  is  divided  into  two  parts,  the  larger  of  which 
is  situated  in  the  upper  external  angle  of  the  orbit,  while  the  smaller  is 
placed  just  beneath  the  mucous  membrane  of  the  fornix. 

The  remainder  consists  of  the  puncta  lachrymalia,  the  canaliculi, 
the  sac  and  nasal  duct  (see  Fig.  18).  The  puncta  are  seen  as  minute 
openings  at  the  inner  extremity  of  each  lid  about  six  millimeters  from 


THE   ORBIT   AND    EYE.  99 

the  internal  canthus.  The  canaliculi  are  the  continuations  of  the  puncta, 
extending  vertically  for  a  short  distance,  and  then  continuing  horizon- 
tally, emptying  into  the  lachrymal  sac.  The  lachrymal  sac  is  situated 
in  a  groove  at  the  inner  angle  of  the  orbit,  and  empties  in  the  nasal 
duct  (see  Fig.  18).  The  nasal  duct  passes  downward  and  slightly 
outward  and  backward,  varying  in  length  from  twelve  to  twenty-two 
millimeters,  and  in  its  diameter  from  three  to  six  millimeters.  It 
terminates  just  below  the  inferior  turbinate  body. 


100  THE    NECK. 


THE  NECK. 

Examination  of  the  Neck  during  Life.— Where  the  face  passes 
into  the  neck,  the  horseshoe-shaped  border  of  the  lower  jaw  can  be 
felt  as  the  upper  boundary  of  the  neck.  The  lower  boundary  is  formed 
by  the  upper  border  of  the  sternum,  by  the  clavicle  and  a  line  drawn 
from  the  acromioclavicular  joint  to  the  seventh  cervical  spinous  process. 
Beginning  from  above,  one  should  palpate  the  following  points: 

1.  The  lower  border  of  the  lower  jaw. 

2.  Following  downward  in  the  median  line,  the  hyoid  bone,  of  which 
one  can  feel  the  body  and  greater  cornu. 

3.  The  thyroid  cartilage,  the  upper  border  of   which  corresponds 
to  the  point  of  division  of  the  common  carotid  artery  into  the  internal 
and  external  carotids. 

4.  The  cricoid  cartilage  immediately   below   the   thyroid.     When 
the  head  is  drawn  backward,  one  can  feel  between  these  two  cartilages 
the  tense  cricothyroid  membrane. 

5.  From  the  cricoid  cartilage  downward  to  the  upper  border  of  the 
sternum,  the  upper  five  or  six  tracheal  rings  can  be  felt  just  beneath 
the  skin,  especially  when  the  head  is  thrown  backward. 

6.  External  to  the  median  line,  on  both  sides,  palpate  the  sterno- 
cleidomastoid  muscle  from  its  point  of  origin  at  the  mastoid  process 
to  its  insertion  at  the  sternoclavicular  joint.     There  is  occasionally 
a  space  between  its  sternal  and  clavicular  attachments. 

7.  Along  the  anterior  border  of  this  muscle  can  be  felt  the  pulsations 
of  the  common  carotid  artery,  and  if  the  fingers  are  pushed  in  still 
deeper,  the  transverse  processes  of  the  third  to  seventh  cervical  verte- 
brae can  be  felt.    The  transverse  process  of  the  sixth  is  quite  prominent, 
and  is  frequently  called  the  carotid  tubercle,  being  a  favorite  point  of 
ligation  of  the  common  carotid  artery. 

8.  When  the  head  is  turned  to  one  side,  note  the  external  jugular 
vein  extending  from  the  middle  of  the  clavicle  to  the  angle  of  the  jaw. 
This  can  be  made  more  prominent  by  compressing  it  at  its  lower  end. 
In  some  individuals  there  is,  under  normal  conditions,  a  venous  pulse 
visible  in  this  vein. 

9.  Palpate  the  trapezius  muscle,  extending  from  the  superior  curved 
line  of  the  occipital  bone  to  the  spine  of  the  scapula  and  clavicle.     It 
can  be  made  especially  prominent  when  the  head  is  drawn  to  one  side. 

10.  Under  these  conditions  palpate  the  space  between  the  posterior 
border  of  the  sternocleidomastoid  muscle  and  the  anterior  border  of 


SURFACE  MARKINGS  OF  NECK.  IOI 

the  trapezius.  This  is  the  posterior  triangle  of  the  neck.  At  its  lower 
portion  can  be  distinctly  felt  the  pulsations  of  the  subclavian  artery, 
and  a  little  higher  up,  a  number  of  firm  cords  passing  obliquely  from 
the  spine  toward  the  arm — the  brachial  plexus. 

Surface  Markings  of  Neck  (see  Figs.  27  and  28). 
Mark  the  following  structures : 

1.  External  jugular  vein  from  middle  of  clavicle  to  angle  of  jaw. 

2.  Common  carotid  artery  from  sternoclavicular  joint,  along  anterior 
border  of  sternocleidomastoid  muscle  to  upper  border  of  thyroid  cartilage. 

3.  External  and   internal   carotid  from  upper  border  of  thyroid 
cartilage  along  anterior  border  of  sternocleidomastoid  muscle  to  a  point 
midway  between  angle  of  jaw  and  mastoid  process. 

4.  Internal  jugular  vein  and  vagus  nerve — line  drawn  along  middle 
of  sternocleidomastoid  muscle  parallel  to  and  external  to  the  common 
carotid  artery,  the  vagus  nerve  lying  between  the  vein  and  the  artery, 
but  at  a  deeper  level. 

5.  Superior  thyroid  artery — line  drawn  from  the  angle  of  junction 
of  the  sternocleidomastoid  muscle  and  hyoid  bone  obliquely  downward 
and  inward  toward  the  median  line. 

6.  Lingual  artery  above  the  superior  thyroid — line  drawn  from  the 
above-mentioned  angle  of  junction  of  the  hyoid  bone  and  sternocleido- 
mastoid muscle  at  first  parallel  to  the  hyoid  bone,  then  obliquely  up  and 
inward  toward  the  lower  jaw. 

7.  Facial  artery — line  from  above  angle  in  a  tortuous  manner  to 
anterior  border  of  masseter  muscle  and  lower  border  of  lower  jaw. 

8.  Occipital  artery — line  from  point  of  origin  of  facial  artery  to 
point  midway  between  mastoid  and  occipital  protuberance. 

9.  Subclavian  artery  and  vein  correspond  to  a  curve  with  convexity 
upward,  drawn  from  sternoclavicular  joint  to  middle  of  lower  border  of 
clavicle,  the  summit  being  one  and  a  half  inches  above  the  latter;  the 
third  portion  of  subclavian  corresponds  to  posterior  border  of  sterno- 
cleidomastoid muscle.     The  subclavian  vein  lies  immediately  in  front 
of,  and  below,  the  artery. 

10.  Phrenic  nerve — line  parallel  to  middle  of  sternocleidomastoid 
muscle  from  hyoid  bone  downward. 

11.  Spinal  accessory  nerve — emerges  opposite  middle  of  posterior 
border  of  sternocleidomastoid  muscle,  passing  obliquely  across  posterior 
triangle  to  anterior  border  of  trapezius  muscle  at  level  of  seventh  cervical 
vertebra. 

12.  The  superficial  cervical  nerves  all  emerge  close  to  the  middle  of 


102  THE    NECK. 

the  posterior  border  of  sternocleidomastoid  muscle;  the  great  auricular 
and  small  occipital  passing  upward  and  backward  to  the  skull,  the  super- 
ficial cervical  winding  around  the  muscle  toward  the  median  line  in 
front,  and  the  three  descending  branches,  supraclavicular,  supra- 
sternal,  and  supra -acromial,  directly  down  and  outward. 

13.  Sympathetic    nerve — line    following    closely    that    of    common 
carotid  artery,  its  superior  cervical  ganglion  being  opposite  the  second 
or  third  cervical  vertebra. 

14.  Brachial  plexus,  corresponds  to  a  line  drawn  from  a  point  oppo- 
site the  cricoid  cartilage — that  is,  about  middle  of  sternocleidomastoid 
muscle — to  one  a  little  external  to  the  middle  of  the  clavicle. 

For  practical  purposes  we  may  divide  the  neck  into  three  regions : 

1.  Anterior — bounded  above  by  the  lower  jaw. 

below  by  the  sternum. 

laterally  by  the  sternomastoid  muscles. 

2.  Lateral — bounded  anteriorly  by  the  sternomastoid  muscles. 

posteriorly  by  the  trapezius. 
below  by  the  clavicle. 

3.  Posterior — embracing  the  remainder. 

The  anterior  region  may  be  subdivided  on  each  side  of  the  median 
line  into  a  (i)  submaxillary  region,  or  triangle;  (2)  carotid  region,  or 
triangle  (see  Figs.  27  and  28). 

The  skin  of  the  anterior  region  is  fine,  very  elastic,  and  readily 
adapts  itself  for  plastic  operations.  It  is  freely  movable  everywhere 
upon  the  underlying  structures.  It  contains,  especially  under  the  jaw, 
many  sebaceous  glands,  which  are  a  frequent  seat  of  acne  and  also 
develop  into  sebaceous  cysts.  The  latter  are,  like  those  of  the  scalp, 
very  superficially  situated.  The  skin  over  them  is  stretched  and,  unless 
inflamed,  freely  movable.  The  subcutaneous  tissue,  especially  in  the 
obese,  contains  much  fat,  giving  rise  at  times  to  a  prominence  below 
the  chin  (double-chin).  Not  infrequently  lipomata  will  form  in  this 
layer,  sometimes  quite  circumscribed,  but  often  quite  diffuse  and  more 
or  less  symmetrically  situated  (symmetrical  lipomatosis).  The  small 
veins  and  lymphatics  of  this  layer  may  be  the  seat  of  congenital  cystic 
tumors  (hemangioma  and  lymphangioma),  which  may  attain  an  enor- 
mous size,  penetrating  the  fascia  and  passing  around  the  deeper  struc- 
tures in  all  directions  (see  Fig.  29). 

Following  scarlatina,  a  severe  phlegmonous  inflammation  of  this 
connective  tissue  occurs  (angina  ludovici),  beginning  at  the  floor  of 
the  mouth  and  spreading  rapidly  downward,  giving  rise  to  a  tense, 
brawny  infiltration  of  the  skin  and  underlying  fibrous  tissue.  Imme- 


Fig.  27. — Surface  markings  of  superficial  structures  of  side  of  face  and  neck,  i,  2, 
and  3,  Points  of  emergence  of  supra-orbital,  infra-orbital,  and  mental  nerves  respectively. 
4,  Parotid  gland.  Just  above  the  figure  the  facial  nerve  is  seen  dividing  inside  of  the 
gland  into  six  principal  branches.  5,  Superficial  temporal  artery  dividing  into  its  anterior 
and  posterior  branches.  6,  Steno's  duct  opening  opposite  second  upper  molar  tooth. 
7,  Facial  artery.  8,  Sternocleidomastoid  muscle.  9,  Points  of  emergence  of  superficial 
cervical  and  spinal  accessory  (in  heavy  outline)  nerves  opposite  middle  of  posterior  border 
of  Sternocleidomastoid.  10,  Trapezius  muscle,  u,  Surface  marking  of  external  jugular 
vein  from  middle  of  clavicle  to  angle  of  jaw.  SM,  Submaxillary  triangle.  SC,  Superior 
carotid  triangle.  L,  Inferior  carotid  triangle.  OC,  Occipital  triangle.  SB,  Subclavian 
triangle. 


103 


Fig.  28. — Surface  markings  of  deeper  structures  of  face  and  neck.  V,  Fifth  nerve 
with  its  three  principal  branches  emerging  from  Gasserian  ganglion,  i,  Placed  upon 
condyle  of  lower  jaw,  the  thick  black  line  above  it  representing  the  temporomaxillary 
joint.  2,  Internal  maxillary  artery,  the  branch  passing  upward  representing  the  middle 
meningeal.  3,  Posterior  auricular  artery.  4,  Occipital  artery.  5,  Facial  artery.  6, 
Lingual  artery.  7,  Superior  thyroid  artery;  immediately  below  its  lower  end,  the  inferior 
thyroid  branch  of  the  subclavian  is  seen.  8,  Placed  just  above  the  bifurcation  of  the 
common  carotid  into  the  internal  and  external  carotids.  9,  Internal  jugular  vein.  Heavy 
black  line  between  8  and  9  represents  the  vagus  nerve  lying  between  the  common  carotid 
artery  and  internal  jugular  vein,  but  at  a  deeper  level.  10,  Spinal  accessory  nerve  as  it 
passes  across  the  posterior  triangle  of  the  neck.  1 1,  Upper  border  of  apex  of  lung.  Note 
its  relation  to  12,  the  brachial  plexus.  13,  The  subclavian  artery.  14,  The  thoracic 
duct. 


105 


Fig.  29. — Congenital  tumor,  child's  neck  (cavernous  hemiangioma) . 


Fig.  30. — Cross-section  of  neck  at  level  of  larynx,  showing  arrangement  of  deep 
cervical  fascia,  etc.  i,  External  jugular  vein.  2,  Sternocleidomastoid  muscle.  3, 
Internal  jugular  vein.  To  its  inner  side  is  seen  the  common  carotid  artery,  and  lying 
between  the  two,  but  at  a  posterior  level,  the  vagus  nerve  on  each  side  (white  dot).  4, 
Placed  in  larynx  between  true  vocal  cords.  5,  Placed  between  cricoid  and  thyroid  carti- 
lages. 6,  Sternohyoid  muscle.  7,  Thyroid  gland.  8,  Body  of  cervical  vertebra.  9, 
Brachial  plexus.  10,  Trapezius  muscle,  n,  Muscles  at  back  of  neck.  The  line  points 
to  the  middle  (previsceral)  layer  of  the  deep  cervical  fascia,  and  can  be  followed  forward. 
12,  Vertebral  vessels  and  sympathetic  nerve.  The  dotted  line  represents  the  prevertebral 
layer  of  the  deep  cervical  fascia.  Between  the  cricoid  cartilage  (5)  and  the  body  of  the 
vertebra  (8),  but  separated  from  it  by  the  prevertebral  fascia,  is  seen  the  esophagus. 

107 


SUBMAXILLARY    REGION,    OR    TRIANGLE.  IOO, 

diately  beneath  the  cellular  tissue  is  the  superficial  or  outer  layer  of  the 
deep  fascia,  which  forms  a  firm  investment  for  the  organs  of  the  neck. 
Its  upper  limit  extends  from  the  occiput  to  the  chin;  its  lower  is  attached 
to  the  sternum,  clavicle,  acromion,  and  spine  of  the  scapula  (see  Figs.  30 
and  31).  It  is  attached  behind  to  the  ligamentum  nuchae  and  is  contin- 
uous across  the  median  line  in  front.  It  divides  to  include  the  sterno- 
mastoid  and  trapezius  muscles  (see  Figs.  30  and  31).  Opposite  the  hyoid 
it  divides  to  inclose  the  submaxillary  gland,  and  is  then  attached  to  the 
jaw  (Fig.  31).  For  these  reasons  abscesses  of  the  submaxillary  gland  are 
under  great  tension  and  often  take  a  deeper  course.  Abscesses  situated 
elsewhere  tends  to  gravitate  toward  the  lower  attachment  of  the  fascia, 
or,  if  from  the  spine,  are  limited  by  the  sternomastoid  and  trapezius 
muscles,  often  lying  within  their  fascial  sheath.  Along  the  anterior 
border  of  the  sternomastoid  there  are  frequently  situated  the  openings 
of  certain  congenital  fistulae,  known  as  branchial.  They  are  the  rem- 
nants of  clefts  lined  by  flat-cell  epithelium  which  lie  between  the  branchial 
arches  in  early  embryonic  life  and  permit  of  communication  between 
the  surface  and  the  pharynx.  These  may  close  imperfectly,  remaining 
open  at  either  end.  If  the  external  openings  remain,  they  are  usually  at 
the  sternoclavicular  joint  (last  cleft,  see  Fig.  32)  or  opposite  the  larynx. 
If  the  opening  of  the  incomplete  canal  is  external,  it  is  usually  situated 
at  the  beginning  of  the  esophagus,  or  at  the  posterior  pillar  of  the  fauces, 
near  the  tonsils.  They  admit  a  fine  probe.  Branchial  cysts  arise  from 
the  retention  of  secretion  in  such  a  canal.  They  usually  appear  in 
adolescence.  If  placed  near  the  cutaneous  end,  the  secretion  is  seba- 
ceous (deep  atheroma) ;  if  near  the  pharynx,  glairy  mucus.  The  most 
common  situation  of  these  cysts  is  in  the  third  cleft  between  the  thyroid 
gland  and  sternomastoid  muscle.  An  epithelioma  may  develop  from 
the  squamous  epithelium  lining  the  cleft,  characterized  by  a  deep-seated 
tumor  beneath  the  sternomastoid,  indefinite  in  outline  and  of  firm 
consistence  (branchiogenic  carcinoma).  Another  embryonic  structure 
may  occasionally  persist,  the  thyroglossal  duct,  and  open  at  the  upper 
border  of  the  thyroid  cartilage  (see  Fig.  32). 

Submaxillary  Region,  or  Triangle  (see  Figs.  27  and  33). 

Upper  boundary — Lower  jaw  and  line  continued  to  mastoid  process 
forms  base  of  triangle. 

T  from  anterior  portion  of  hyoid  bone  to 
Lower  boundary — in  front  <  chin  corresponds  to  anterior  belly  of 

I      digastric. 

(  L  e.,  from  mastoid  to  anterior  portion 
Lower  boundary — behind  <  of  hyoid  bone,  corresponds  to  poste- 

t      rior  belly  of  digastric. 


110  THE    NECK. 

The  superficial  layer  contains  (beneath  the  superficial  layer  of  the 
deep  fascia)  the  anterior  facial  vein,  which  crosses  the  region  from  the 
lower  jaw  to  empty  into  the  anterior  jugular  (see  Fig.  33).  It  may  be- 
come thrombosed  in  cellulitis  of  the  neck  and  the  thrombophlebitis 
may  spread  upward  along  the  internal  jugular  vein  and  cause  menin- 
gitis. The  facial  vein  accompanies  the  facial  artery,  which  is  far  more 
tortuous,  dipping  in  at  times  to  the  floor  of  the  mouth,  so  close  to  the 
tonsil  that  it  may  occasionally  be  cut  tangentially  by  a  tonsillotome. 
Almost  the  entire  superficial  layer  is  occupied  by  the  submaxillary 
salivary  and  lymph-glands,  inclosed  between  the  two  layers  of  deep 
cervical  fascia  above  described  (see  Fig.  31).  The  lymph-glands  are 
often  imbedded  within  the  submaxillary  salivary  gland.  They  drain 
the  cheek,  gums  of  lower  jaw,  and  lateral  portion  of  lips  and  tongue 
(see  Fig.  34).  Hence  they  are  enlarged  in  infectious  or  malignant  pro- 
cesses involving  these  parts;  e.  g.,  carious  teeth  or  carcinoma  of  lips 
and  of  tongue.  In  infectious  processes,  especially  in  children,  they 
readily  form  an  abscess.  In  malignant  or  tubercular  disease  their  re- 
moval may  necessitate  extirpation  of  the  submaxillary  salivary  gland. 
The  latter  is  frequently  the  seat  of  an  epidemic  inflammation,  like 
the  parotid.  (Submaxillary  "  mumps.") 

In  the  same  layer  near  the  median  line,  beneath  the  chin  and  be- 
tween the  two  anterior  bellies  of  the  digastric  muscles,  are  several  glands 
(submental)  which  drain  the  median  portion  of  the  lower  lip  and  must 
be  examined  in  cases  of  carcinoma  of  the  lower  lip. 

The  submaxillary  gland  is  separated  by  a  layer  of  fascia  from  the 
deep  layer  of  this  region  (see  Fig.  33).  Immediately  beneath  it  are  the 
styloglossus  and  hyoglossus  muscles  externally,  and  the  mylohyoid  to 
the  median  side.  The  two  latter  muscles  unite  (mylohyoid  of  each  side) 
in  the  median  line  to  form  the  floor  of  the  mouth.  The  hypoglossal 
nerve  lies  upon  the  hyoglossus  muscle  accompanied  by  the  lingual  vein, 
crossing  it  obliquely  to  dip  under  the  external  border  of  the  mylohyoid 
and  then  pass  upward  to  the  tongue.  Immediately  above  it  is  Wharton's 
duct,  which  also  crosses  the  hyoglossus  muscle  and  the  lingual  nerve, 
lying  close  to  the  inner  margin  of  the  lower  jaw  until  near  the  median 
line,  where  it  passes  upward  into  the  mouth.  Unless  care  is  taken 
in  the  removal  of  the  submaxillary  glands,  the  hypoglossal  nerve 
may  be  injured,  being  separated  only  by  a  layer  of  fascia.  The  lin- 
gual artery  passes  across  the  greater  cornu  with  the  hypoglossal  nerve> 
but  instead  of  passing  obliquely  up  and  inward  like  the  nerve,  it 
lies  parallel  at  first  with  the  hyoid  (beneath  the  hyoglossus  muscle), 
then  passes  vertically  up  to  the  tongue.  It  is  often  ligated  prelim- 


Lower  jaw 

Submaxillary  gland 

Hyoid 

Outer  layer  of  deep 
cervical  fascia 


Thyroid  gland  in- 
closed in  capsule 
of  middle  layer 


Middle  layer  of 

deep  cervical  fascia 

(previsceral  layer) 


Anterior 
mediastinum 


Superior  vena  cava 


Arch  of  aorta 


Vault  of  pharynx 


Prevertebral 

space 


—  Epiglottis 


Deep  layer  (pre- 
vertebral) 


—  Trachea 


YV Esophagus 


Wall  of  trachea 

Posterior  medi- 
astinum 


Posterior  medi- 
astinum 


Fig.  31. — Vertical  view  of  deep  cervical  fascia  (diagrammatic),  showing  how  sup- 
puration may  extend  by  continuity  from  the  head  and  neck  to  the  anterior  and  posterior 
mediastinum. 


in 


Fig.  32. — Surface  markings  of  principal  structures  of  neck,  and  of  thorax  in  child. 
i,  Upper  border  of  thyroid  cartilage.  2,  Cricoid.  3,  Rings  of  trachea  above  isthmus 
of  thyroid.  3',  Rings  of  trachea  below  isthmus  of  thyroid.  4,  Isthmus  of  thyroid.  5, 
Common  carotid  artery.  6,  Anterior  border  of  the  sternocleidomastoid.  7,  Subclavian 
artery.  8,  Innominate  artery.  9,  Right  innominate  vein.  9',  Left  innominate  vein.  10, 
Superior  vena  cava.  n,  Line  of  absolute  cardiac  dullness,  according  to  Sahli.  12,  Area 
of  absolute  cardiac  dullness.  13,  Right  auricle.  14,  Left  auricle.  15,  Right  ventricle. 
1 6,  Left  ventricle.  17,  Lower  border  of  pleura.  18,  Pulmonary  artery.  A,  Aorta.  Th, 
Thymus  gland.  M  (in  neck),  Most  frequent  opening  of  thyroglossal  duct.  L,  Most 
frequent  openings  of  branchial  fistulae.  M  (in  thorax),  Mammary  line.  P,  Parasternal 
line. 


SUBMAXILLARY    REGION,    OR    TRIANGLE.  115 

inary  to  removal  of  the  tongue  and  can  be  found  by  pulling  the 
submaxillary  gland  upward  when  the  hypoglossal  nerve  is  exposed. 
The  hyoglossus  muscle  which  lies  beneath  the  nerve  is  then  divided 
transversely  and  the  artery  is  readily  found.  To  the  outer  side  of 
the  artery  is  the  glossopharyngeal  nerve  at  a  still  deeper  level, 
accompanied  by  the  styloglossus  and  stylopharyngeus  muscles.  The 
latter  lies  directly  upon  the  superior  constrictor  of  the  pharynx, 
being  separated  only  by  mucous  membrane  (Fig.  15).  Close  to 
the  inner  side  of  the  lower  jaw  is  the  lingual  nerve  and  Wharton's 
duct  (Figs.  10  and  33)  on  cither  side  of  the  neck. 
The  carotid  triangle  has  as  its 

1.  Upper  boundary — the  posterior  belly  of  digastric  continued  to  the 
median  line. 

2.  Externally — Sternocleidomastoid  muscle. 

3.  Internally — Median  line. 

The  anterior  belly  of  the  omohyoid  muscle  divides  it  into  a  superior 
and  an  inferior  carotid  triangle;  i.  e.,  all  above  a  line  crossing  the  sterno- 
mastoid,  opposite  the  cricoid  and  prolonged  to  the  hyoid,  forms  the 
superior;  all  below,  the  inferior  (Figs.  27  and  33)  carotid  triangle. 
For  clinical  purposes,  we  shall  speak  of  them  as  one. 

Immediately  beneath  the  fascia  (outer  layer  of  deep)  (see  Fig.  30) 
are  the  anterior  jugular  veins,  which  send  many  branches  across 
the  median  line  (see  Figs.  32  and  33).  In  cases  of  diphtheria  or 
any  other  form  of  laryngeal  or  tracheal  stenosis  they  become  en- 
gorged and  may  give  rise  to  considerable  hemorrhage  during  trache- 
otomy. Immediately  beneath  are  the  stcrnohyoid  and  sternothyroid 
muscles.  The  former  is  nearer  the  median  line;  they  are  of  value  as 
guides  to  the  trachea  lying  beneath  them  (see  Fig.  35).  A  little  more 
externally  is  the  carotid  sheath,  lying  beneath  the  Sternocleidomastoid 
muscle  close  to  its  anterior  border.  Opposite  the  cricoid  the  sheath  is 
crossed  obliquely  by  the  omohyoid  muscle  lying  beneath  the  Sterno- 
cleidomastoid (see  Fig.  33).  The  sternomastoid,  as  stated  above,  is 
inclosed  in  a  sheath  of  the  outer  layer  of  the  deep  cervical  fascia.  It 
is  supplied  by  the  spinal  accessory  nerve,  which  enters  it  opposite  the 
hyoid  and  emerges  from  it  at  the  middle  of  the  posterior  border  (Figs. 
27  and  33).  This  muscle  is  at  times  injured  during  birth,  and  the 
resulting  hematoma  and  cicatrix  may  be  mistaken  for  a  tumor.  In 
congenital  wryneck  due  to  rigid  contraction  of  the  muscle  the  chin  is 
turned  toward  the  sound  side  and  the  head  is  brought  down  to  the 
affected  side.  The  muscle  may  contract  spasmodically  (either  directly 
or  reflexly),  necessitating  operation  on  the  spinal  accessory  supply- 


Il6  THE    NECK. 

ing  it.  Tenotomy  of  this  muscle  is  best  performed  by  the  open 
method. 

On  its  anterior  surface  (external  to  the  fascia  inclosing  it)  the  muscle 
is  crossed  by  the  external  jugular  vein  opposite  its  middle  (see  Figs.  27  and 
33).  On  its  posterior  surface  the  muscle  is  in  relation  with  the  superfi- 
cial branches  of  the  cervical  plexus  which  emerge  from  its  posterior  border 
at  about  its  middle,  with  the  brachial  plexus,  the  carotid  sheath  (Figs. 
27  and  30),  and  below  with  the  subclavian  vessels  (Figs.  33,  35,  and  36). 
Along  both  of  its  borders  and  beneath  it  are  many  lymph-nodes  (deep 
cervical),  so  that  the  muscle  must  be  pulled  forward  or  backward  in 
their  removal.  At  times  a  temporary  resection  of  the  muscle  has  been 
made  to  facilitate  their  removal.  These  glands  receive  their  lymph 
from  the  interior  of  the  skull  (temporal  and  sphenomaxillary  fossa?, 
orbits,  tongue,  larynx,  nose,  upper  jaw,  palate,  pharynx,  and  thyroid) 
(see  Fig.  34).  Hence  their  frequent  enlargement  when  the  infection 
atria  have  been  in  the  mouth,  nose,  or  pharynx  (diseased  tonsils,  ade- 
noids, carious  teeth,  middle-ear  disease,  etc.).  They  form  firm  adhe- 
sions to  the  carotid  sheath,  especially  to  the  internal  jugular  veins,  their 
removal  often  resulting  in  injury  to  the  important  structures  contained 
in  the  sheath  or  to  the  spinal  accessory  nerve  before  or  after  its  passage 
through  the  sternomastoid  muscle. 

In  the  carotid  sheath,  formed  by  the  deep  layer  of  the  cervical  fascia, 
lie  the  common  carotid  artery  close  to  the  anterior  border  of  the  sterno- 
mastoid, the  internal  jugular  vein  on  the  outer  side,  and,  at  a  deeper  level 
between  these,  the  vagus  (see  Figs.  27,  28,  30,  32,  33,  and  35).  Inclosed 
in  this  sheath  are  also  a  number  of  the  deep  cervical  lymph-glands. 
The  internal  jugular  is  more  closely  attached  to  the  sternomastoid 
muscle  than  the  carotid  is.  Opposite  the  upper  border  of  the  thyroid 
cartilage,  the  point  of  division  of  the  common  carotid,  the  internal 
carotid  continues  to  the  base  of  the  skull,  lying  close  to  the  vertebrae, 
while  the  external  remains  more  superficial  (Figs.  27  and  33).  Just 
below  the  lower  jaw  the  internal  jugular  is  crossed  by  the  hypoglossal. 
Further  down,  both  this  vein  and  the  common  carotid  are  crossed  by 
the  descendens  hypoglossi.  In  children  the  upper  half  of  the  carotid 
sheath  is  entirely  exposed  on  account  of  the  small  sternocleidomastoid 
(see  Fig.  32).  The  sympathetic  and  its  ganglia  lie  immediately  behind 
the  carotid  sheath,  especially  behind  the  artery.  The  sympathetic 
nerve  rests  upon  the  muscles  in  front  of  the  spine  (Fig.  30).  The 
superior  ganglion  lies  at  the  level  of  the  second  or  third  vertebra  and  is 
resected  for  exophthalmic  goiter  (Jonnesco). 

Immediately   beneath    the   sternohyoid    and    sternothyroid    in    the 


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Fig.  34. — Superficial  and  deep  lymphatics  of  head  and  neck:  i,  Lymphatic  in  cheek. 
2,  Glands  in  front  of  ear  and  inside  of  parotid  gland.  3,  Submaxillary  glands.  4,  Sub- 
mental  glands.  5,  Posterior  auricular  glands.  6,  Superficial  lymphatics  along  sterno- 
cleidomastoid  muscle.  7,  Deep  lymphatics  along  carotid  sheath,  beneath  sternocleido- 
mastoid  muscle.  8,  Supraclavicular  glands.  9,  Anterior  mediastinal  glands.  10, 
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119 


SUBMAXILLARY    REGION,    OR    TRIANGLE.  121 

median  line  lie,  from  above  downward,  the  hyoid  bone  and  the  firm 
membrane  connecting  it  with  the  thyroid;  then  the  thyroid  containing 
the  larynx,  and  below  it  the  cricothyroid  membrane  crossed  by  the 
cricoid  artery,  and,  below  this,  the  cricoid  cartilage. 

The  trachea  is  found  in  the  median  line.  Generally  only  the  first 
ring  can  be  seen  of  the  trachea ;  the  second  is  covered  by  the  isthmus  of 
the  thyroid  gland,  and  the  remainder  by  fat  in  the  adult  as  the  trachea 
recedes  from  the  sternum,  or  by  the  thymus  in  children,  even  when 
there  is  no  enlargement  of  the  thyroid  (see  Figs.  30,  32,  33,  and  36). 
The  trachea  is  crossed  by  the  inferior  thyroid  veins  (see  Fig.  33). 

The  hyoid  bone  lies  immediately  below  and  supports  the  base  of 
the  tongue  and  the  epiglottis  (Fig.  23).  Its  body  and  greater  cornua 
give  attachment  to  the  principal  extrinsic  muscles  of  the  tongue  and  to 
the  depressors  of  the  lower  jaw.  Injury  to  the  hyoid  may  result  in  a 
fracture  (in  hanging,  or  blows).  Below  it  is  the  thyrohyoid  mem- 
brane. This  is  at  times  divided  in  order  to  gain  access  to  foreign  bodies 
at  the  orifice  of  the  larynx  (low  lateral  pharyngotomy).  It  is  opposite 
the  epiglottis,  and  after  it  has  been  divided  the  entire  upper  opening 
of  the  larynx  is  exposed,  as  wrell  as  the  lower  parts  of  the  pharynx. 
The  operation  must  be  preceded  by  a  tracheotomy. 

Below  the  cricothyroid,  in  the  median  line,  are  the  thyroid  and  cri- 
coid cartilages  containing  the  larynx.  The  thyroid  cartilage  is  ossified 
after  the  age  of  fifty,  and  may  be  fractured  by  blows,  by  strangulation, 
or  by  gunshot  wounds.  The  larynx  is  best  seen  from  the  oropharynx, 
by  laryngoscopic  examination  (see  Figs.  30  and  38).  In  front,  at 
the  base  of  the  tongue,  is  the  epiglottis.  Running  backward  on  each 
side  are  two  folds  of  mucous  membrane  (aryteno-epiglottic)  passing 
to  two  prominences  behind,  the  arytenoid  cartilages.  The  space 
between  these  is  the  superior  aperture  of  the  larynx.  Between  it  and 
the  lateral  walls  of  the  pharynx  there  is  a  pocket  on  each  side,  sinus 
pyriformis,  which  is  at  times  the  starting-point  of  an  cpithelioma,  and  a 
frequent  location  of  small  foreign  bodies.  Looking  down  through  the  su- 
perior aperture,  the  false  vocal  cords  can  be  seen  at  about  the  level  of  the 
middle  of  the  thyroid  cartilage.  Immediately  below  them  is  the  rima,  or 
chink  of  the  glottis,  or  space  between  the  true  vocal  cords  (Fig.  30).  The 
mucous  membrane  and  muscles  of  the  larynx  are  supplied  by  the  superior 
and  inferior  laryngeal  nerves;  the  superior  supplies  the  mucosa  down  to 
the  vocal  cords  and  also  the  cricothyroid  muscle  (renders  cords  tense) ; 
the  inferior  supplies  the  remainder  of  the  mucosa  and  the  other  mus- 
cles of  the  larynx.  Hence,  when  the  superior  laryngeal  terminal  fila- 
ments are  irritated,  we  have  reflex  spasm  of  the  glottis;  if  paralyzed, 
8 


122  THE    NECK. 

foreign  bodies  can  enter  the  larynx  owing  to  the  insensibility  of  the  epi- 
glottis. When  the  trunk  is  pressed  on,  there  results  a  dry,  brassy  cough 
(loss  of  tension  of  the  cords).  When  the  recurrent  laryngeal  nerves  are 
irritated,  spasm  of  the  muscles  of  larynx  follows;  if  paralyzed,  cadaver 
position  of  cords,  one  or  both  sides.  Such  a  condition  may  happen 
after  diphtheria  or  bulbar  paralysis.  In  aneurisms  of  the  arch  of  the 
aorta  or  of  the  subclavian  or  innominate  arteries,  or  in  mediastinal 
tumors  or  cancer  of  the  upper  part  of  the  esophagus,  it  may  also  occur, 
because  the  left  recurrent  laryngeal  (see  Figs.  37  and  57)  winds  around 
the  arch  of  the  aorta,  the  right  passing  around  the  subclavian  artery. 

The  submucous  tissue  of  the  aryteno-epiglottidean  folds,  and  that 
of  the  interior  of  the  larynx  down  to  the  true  cords,  is  quite  easily  dis- 
tended by  fluid  (serum).  In  acute  inflammatory  conditions  its  swelling 
causes  a  narrowing  of  the  superior  aperture  of  the  larynx  (laryngeal 
stenosis  or  edema  of  glottis).  This  takes  place  more  readily  in  children 
(catarrhal  croup)  on  account  of  the  relatively  small  size  of  the  larynx. 
For  the  relief  of  edema  of  the  glottis,  as  well  as  for  the  stenosis  due  to 
a  false  membrane  occluding  the  aperture,  intubation  is  practised  with 
excellent  results.  The  main  anatomic  points  to  be  remembered  in 
this  operation  are: 

1.  The  finger  (index),  after  having  been  passed  well  back  into  the 
pharynx  and  brought  forward  in  the  median  line,  encounters  a  hard 
nodule,  the  cricoid  cartilage  (see  Fig.  23). 

2.  At  the  same  level  is  the  opening  of  the  larynx  and  the  epiglottis. 

3.  If  the  tube  is  not  kept  in  the  median  line,  and  in  front  of  the  above 
nodule,  it  is  passed  either  into  the  esophagus  or  into  one  of  the  ventricles 
of  the  larynx  between  the  true  and  false  vocal  cords. 

Behind  the  thyroid  and  cricoid  are  the  pharynx  and  esophagus, 
being  separated  only  by  a  thin  layer  of  muscle.  Externally,  both  cricoid 
and  thyroid  are  covered  by  the  thyroid  gland  (see  Figs.  30,  32,  33, 
35,  36,  and  37).  Between  these  cartilages  and  the  esophagus  laterally, 
and  in  immediate  contact  with  both,  are  the  recurrent  laryngeal  nerves, 
and  a  little  more  externally,  the  carotid  sheath  (see  Figs.  37  and  57). 
Laryngectomy  is  performed  for  malignant  tumors  of  the  larynx. 
The  principal  anatomic  relations  to  be  remembered  are  (see  Figs. 
33  and  37): 

1.  The  larynx  can  be  best  reached  by  an  incision  made  from  the 
hyoid  to  the  third  tracheal  ring  in  the  median  line. 

2.  Principal    blood-vessels    are    superior    laryngeal    artery    (upper 
border  of  thyroid);  cricothyroid  artery,  between  cricoid  and  thyroid 
cartilages;  inferior  laryngeal,  upper  border  of  cricoid.     These  all  lie 


SUBMAXILLARY    REGION,    OR   TRIANGLE.  123 

between  the  sternohyoid  and  thyroid  muscles  and  the  cartilages  (Fig. 

33)- 

3.  Nerves.     Superior  laryngeal,  level  of  upper  border  of  thyroid, 
immediately  below  the  same  artery.     Inferior  or  recurrent  laryngeal 
in  the  groove  between  esophagus  and  larynx  as  far  up  as  cricothyroid 
membrane  (Figs.  35  and  37). 

4.  Esophagus  and  pharynx,  latter  from  upper  border  of  cricoid  up; 
former  from  that  point  down,  are  separated  only  by  thin  layer  of  mus- 
cle (Fig.  35). 

5.  External  carotid  and  superior  thyroid  arteries  lie  just  external  to 
the  thyroid  and  cricoid  cartilages  (see  Figs.  27  and  33). 

Below  the  cricoid,  and  firmly  connected  with  it,  is  the  trachea. 

Under  normal  conditions  the  first  ring  is  usually  free;  the  second 
and  third  covered  by  the  isthmus  of  the  thyroid  (Figs.  32  and  36).  The 
upper  rings  are  quite  superficially  situated,  but  as  the  trachea  passes 
downward,  it  recedes  from  the  surface,  so  that  the  various  structures 
of  the  lower  portion  of  the  neck  itself  intervene  between  it  and  the 
skin,  in  addition  to  the  muscles,  fat  in  adults,  and  the  upper  end  of  the 
thymus  gland  in  children  (Fig.  31).  The  inferior  thyroid  veins  pass 
across  it  at  its  lower  portion,  and  from  these,  occasionally  the  large 
median  thyroid  (thyroidea  ima)  vein  passes  along  the  middle  of  the 
front  of  trachea  (Fig.  33). 

The  operation  of  tracheotomy  is  performed  for  the  purpose  of 
relieving  laryngeal  stenosis,  after  unsuccessful  intubation,  or  when  the 
latter  is  impossible,  or  as  a  preliminary  operation  to  removal  of  the 
tongue,  etc.  It  is  performed  either  above  or  below  the  isthmus  of  the 
thyroid  gland  (second  and  third  rings  of  trachea).  The  former  (high) 
operation  is  preferable,  because  the  trachea  is  more  superficial  here. 
The  isthmus  of  the  thyroid  is  very  vascular;  hence,  it  should  be  pulled 
downward  to  avoid  injury  to  it.  The  incision  is  made  through  the  skin 
and  intermuscular  septum,  between  the  sternohyoid  and  thyroid  muscles 
(which  latter  are  pulled  back)  to  the  extent  of  about  one  and  a  half  to 
two  inches  from  the  cricoid  downward  in  the  median  line.  The  trachea 
is  fixed  on  each  side  by  a  tenaculum,  especially  in  children,  in  whom  it 
is  very  movable,  and  deeper  than  in  adults.  The  first  and  second  rings 
of  the  trachea  are  incised  in  the  median  line  and  the  cannula  inserted. 
On  account  of  the  proximity  to  the  large  blood-vessels  on  either  side  of 
the  trachea  and  on  account  of  the  esophagus  behind,  any  deviation 
from  the  median  line  will  injure  the  former;  and  too  deep  an  incision 
may  go  through  both  anterior  and  posterior  walls  of  the  trachea  into 
the  underlying  esophagus. 


124  THE    NECK. 

On  either  side  of  the  trachea  are  the  lateral  lobes  of  the  thyroid 
gland.  The  gland  is  firmly  attached  to  the  trachea,  being  inclosed  in  a 
reflection  of  the  deep  cervical  fascia  which  forms  a  capsule  for  the  gland 
(Figs.  31  and  35).  On  account  of  its  firm  attachment  to  the  trachea, 
enlargements  of  the  thyroid  gland  move  upward  during  the  act  of 
swallowing.  The  gland  is  frequently  enlarged,  and,  if  so,  the  tumor 
pushes  its  way  on  either  side  between  the  carotid  sheath  and  the  esoph- 
agus. It  displaces  the  structures  of  the  carotid  sheath  and  the  sterno- 
cleidomastoid  muscle  outward.  It  may  press  upon  the  recurrent 
laryngeal  nerves  which  lie  (Figs.  35,  37,  and  57)  between  the  esophagus 
and  trachea,  causing  either  hoarseness  or  complete  paralysis  of  the  vocal 
cords,  or  may  press  upon  the  sympathetic  nerve,  causing  dilatation  of 
the  pupil  of  the  same  side.  On  account  of  its  practically  surrounding 
the  trachea,  a  tumor  of  the  thyroid  gland,  especially  if  of  long  standing, 
can  compress  the  lateral  aspects  of  the  trachea,  causing  the  formation 
of  the  deformity  known  as  sabre-sheath*  trachea.  Such  a  tumor  may 
not  only  grow  backward,  compressing  the  above  structures  and  esoph- 
agus, but  grow  toward  the  skin,  causing  a  marked  prominence  at  the 
lower  portion  of  the  neck. 

In  any  operation  upon  this  gland,  the  following  points  are  to  be 
remembered:  (i)  The  chief  arterial  supply  is  derived  from  the  superior 
and  inferior  thyroid  arteries.  The  superior  enters  the  gland  opposite  the 
middle  of  the  thyroid  cartilage;  the  inferior,  arising  from  the  thyroid  axis 
of  the  subclavian,  enters  it  opposite  the  cricoid  (see  Figs.  28  and  33). 
(2)  The  inferior  thyroid  artery  is  accompanied  in  the  upper  part  of  its 
course  by  the  recurrent  laryngeal  nerve.  (3)  The  superior  thyroid 
vein  often  accompanies  the  artery;  the  inferior  thyroid  vein  enters  the 
gland  on  either  side  of  the  median  line  at  the  same  level  as  the  artery, 
but  internal  to  it.  The  gland  is  always  inclosed  in  a  capsule  attached  to 
the  trachea. 

Behind  the  trachea  and  larynx,  in  the  median  line,  lies  the  esophagus 
(see  Figs.  30,  31,  35,  37,  and  57).  It  is  separated  from  the  anterior  sur- 
face of  the  vertebrae  (from  its  beginning  at  the  sixth  cervical,  opposite  the 
cricoid  cartilage)  by  a  space  known  as  the  prevertebral,  continuous  above 
with  the  retropharyngeal,  but  narrower  than  the  latter  (Fig.  31).  This 
space  is  formed  by  the  deep  cervical  fascia  (see  below).  The  esophagus 
is  separated  only  by  muscle,  one  centimeter  thick,  from  the  trachea. 
Between  these,  laterally,  the  recurrent  laryngeal  nerve  lies  as  far  up  as 
the  cricothyroid  membrane  (see  Figs.  30,  33,  35,  and  37).  Externally 
lie  at  a  deep  level  the  vagus  and  sympathetic,  and,  more  superficially, 
the  carotid  artery  and  internal  jugular  vein.  Behind  the  trachea  the 


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SUBMAXILLARY    REGION,    OR   TRIANGLE.  127 

esophagus  gradually  lies  to  the  left  of  median  line,  until  at  the  beginning 
of  the  thorax  it  lies  quite  to  the  left  of  the  median  line  (Fig.  57). 
Hence,  to  open  the  esophagus  for  the  removal  of  foreign  bodies  or 
malignant  growths,  the  incision  should  be  on  the  left  side  of  the  neck. 
In  passing  a  stomach-tube  for  the  first  time,  the  finger  should  hold 
down  the  base  of  the  tongue,  and  the  tube  be  passed  toward  the  poste- 
rior wall  of  the  pharynx,  a  little  more  toward  the  left  than  to  the  right. 
Owing  to  the  close  relations  between  the  esophagus,  the  large  vessels 
of  the  neck  and  thorax,  and  pre vertebral  space,  no  force  should  be  used, 
on  account  of  the  danger  of  perforation  into  these,  causing  rupture  of 
a  possible  aneurism,  or  the  formation  of  an  abscess  passing  downward 
to  the  posterior  mediastinum  (Fig.  31).  Foreign  bodies  at  the  beginning 
of  the  esophagus  can  be  removed  by  low  lateral  pharyngotomy,  if  it  is 
impossible  to  extract  them  through  the  mouth  by  various  instruments 
used  for  that  purpose.  Esophageal  bougies  are  passed  in  the  same 
manner  as  a  stomach-tube,  the  first  resistance  being  opposite  the  cricoid 
cartilage  (beginning  of  esophagus),  which  to  those  unaccustomed  to 
passing  it,  gives  the  impression  of  a  stenosis. 

The  esophagus  (esophagotomy)  is  reached  through  an  incision 
three  inches  long,  along  the  anterior  border  of  the  left  sternomastoid 
from  the  level  of  the  cricoid  downward.  The  principal  anatomic 
points  to  be  remembered  are  (see  Fig.  33) : 

1.  The  external  jugular  vein  crosses  at  the  upper  end  of  incision. 

2.  The  carotid  sheath,  crossed  by  the  descendens  hypoglossi,  lies  to 
the  outer  side,  and  must  be  pushed  and  held  outward. 

3.  The  left  lobe  of  the  thyroid  gland  lies  over  the  lateral  aspect  of 
the  esophagus  and  trachea,  and  must  be  retracted  toward  median  line. 

4.  The   recurrent   laryngeal  nerve   lies  deeply  in   groove  between 
esophagus  and  trachea  (see  Figs.  35  and  37). 

Relations  at  Lower  Part  of  Neck  (see  Figs.  32,  33,  35,  36,  37,  and  57). 
Beginning  in  the  Median  Line. — The  trachea  lies  in  the  median 
line;  behind  it  lies  the  esophagus  (a  little  to  the  left  of  it).  In  front  are 
the  inferior  thyroid  veins,  the  left  innominate  vein  (behind  upper  border 
of  sternum),  and  the  innominate  artery.  Between  the  trachea  ,and 
common  carotid  arteries  are  the  recurrent  laryngeal  nerves  on  either  side. 
Externally,  from  within  outward,  behind  the  sternoclavicular  joint,  lie,  on 
the  right  side,  the  innominate  artery  and  vein ;  on  the  left  side,  the  common 
carotid  and  subclavian  arteries  and  innominate  vein.  Above  this  joint, 
on  both  sides  from  within  outward,  the  relations  are  almost  the  same; 
namely,  the  common  carotid  artery,  external  to  which  is  the  internal 


128  THE    NECK. 

jugular  vein  and  vagus  nerve,  the  latter  crossing  the  subclavian  artery 
in  its  first  portion.  At  the  same  level,  still  more  externally,  lie  the 
subclavian  veins,  in  front  of  the  arteries  (Figs.  35  and  37).  On  the  left 
side  the  thoracic  duct  empties  at  the  junction  of  the  subclavian  and 
internal  jugular  veins,  lying  between  the  latter  vein  and  the  subclavian 
artery  behind  (see  Figs.  28  and  33).  Still  further  outward  lie  the 
scaleni  antici  muscles,  and  phrenic  nerves  on  each  side  of  the  neck.  At 
a  deeper  level  lie  on  each  side  the  subclavian  arteries  which  pass  across 
the  first  rib  behind  the  scaleni  antici,  between  these  muscles  and  the 
brachial  plexus,  situated  posterior  to  them.  The  subclavian  arteries 
form  an  arch  whose  course  is  from  the  sternoclavicular  joint  on  each 
side,  to  the  middle  of  the  corresponding  clavicle,  the  summit  being  one 
and  a  half  inches  above  the  latter  bone.  Beneath  this  arch,  in  close 
relation  with  the  subclavian  artery  above  and  the  brachial  plexus  on 
the  outer  side,  is  the  apex  of  the  pleural  cavity  (see  Figs.  28  and  35). 
Aneurisms  of  the  subclavian  artery  may  press  upon  the  apex  of  the 
lung  lying  below  it,  upon  the  vagus  in  front,  and  the  recurrent  laryn- 
geal  on  the  right  side,  where  it  arches  beneath  it  to  reach  the  lateral 
aspect  of  the  trachea  (see  Fig.  37).  The  subclavian  artery  is  most  fre- 
quently ligated  in  its  third  portion,  which  can  be  readily  found  if  it  is 
remembered  that  this  lies  external  to  the  scalenus  anticus  (the  vein  in 
front),  that  is,  a  little  to  the  outer  side  of  the  posterior  border  of  the 
sternomastoid. 

The  chief  branches  of  the  subclavian  artery  are  given  off  in  its  first 
portion,  i.  e.,  to  the  inner  side  of  the  scalenus  anticus.  The  vertebral 
and  internal  mammary  lie  internally,  and  the  thyroid  axis  externally;  the 
inferior  thyroid  branch  of  the  latter  passes  upward,  then  transversely 
across  to  the  trachea,  passing  between  the  carotid  sheath  and  vertebral 
artery  (see  Figs.  28  and  33).  The  vertebral  passes  to  the  transverse 
process  of  the  sixth  cervical  vertebra,  accompanied  by  the  vein.  It 
can  be  reached  by  an  incision  along  the  posterior  border  of  the  sterno- 
cleidomastoid,  pulling  the  carotid  sheath  inward,  and  dissecting  down 
to  the  transverse  process  of  the  sixth  cervical  (see  Fig.  30). 

Deep  Cervical  Fascia. — It  has  already  been  seen  that  the  outer 
layer  starts  in  the  median  line  behind,  and  meets  again  at  the  median 
line  in  front  after  inclosing  the  trapezius  and  sternomastoid  muscles 
and  submaxillary  gland  on  each  side  (see  Figs.  30  and  35).  The  middle 
or  previsceral  layer  begins  also  in  the  median  line  behind,  gives  off 
lamellae  to  inclose  the  muscles  at  the  back  of  the  neck,  and  passes  for- 
ward, forming  the  carotid  sheath  indexing  the  common  carotid,  internal 
jugular  vein,  vagus,  and  a  number  of  dee])  cervical  lymph-glands,  and 


Fig.  36. — View  of  heart  and  large  blood-vessels  of  thorax  and  neck  in  adult,  i, 
Upper  border  of  thyroid  cartilage,  opposite  which  the  common  carotid  divides  into  the 
internal  and  external  carotid  arteries.  2,  Common  carotid  artery.  3,  Internal  jugular  vein. 
4,  External  jugular  vein.  5,  Upper  rings  of  trachea.  6,  Subclavian  artery.  7,  Subclavian 
vein.  8,  Arch  of  aorta.  9,  Superior  vena  cava.  10,  Lateral  lobes  of  thyroid  gland. 
R.B.,  Right  bronchus.  L.B.,  Left  bronchus.  P,  Pulmonary  artery,  xxx,  Tricuspid 
valve.  A,  Aortic  valve.  M,  Mitral  valves.  The  arrow  passing  up  the  aorta  shows  the 
direction  in  which  aortic  murmurs  are  transmitted.  The  arrow  beginning  at  M,  and 
directed  toward  the  apex  of  the  heart,  shows  the  direction  in  which  mitral  murmurs  are 
transmitted.  P,  Position  of  pulmonary  valve. 


129 


Fig.  37. — View  of  relations  of  thyroid  to  recurrent  laryngeal  nerves,  and  of  vessels  at  base 
of  neck  to  pericardium.     (Modified  from  Hildebrand.) 


Facial  nerve 
Cartilaginous  por- 
tion  Eustachian 
tube  and  levator 
palati 


Stylopharyngeus 
Palatopharyngeus 


Lingual  tonsil 


Posterior  crico- 
arvtenoid  muscle 


Antruni  of  mastoid 


Mastoid  cells 
Middle  turbinated 


Inferior  turbin- 

ated 


Azygos  uvulae 
Tonsil 


Aryteno-epiglotti- 
dean  fold 


Aditus  laryngis 

Tubercle  of  San- 
torini 


Beginning  of 
esophagus 


Fig.  38. — Posterior  view  of  pharynx  and  larynx,  as  shown  in  a  coronal  section  of  the  skull  made 
through  the  level  of  the  mastoid  processes. 


133 


RELATIONS  AT  LOWER  PART  OF  NECK.  135 

also  the  omohyoid.  It  then  passes  behind  the  sternohyoid  and  thyroid 
muscles  (hence,  called  pre visceral),  lying  in  front  of  the  trachea  and 
thyroid  gland,  being  continuous  across  the  median  line  with  the  same 
layer  of  the  other  side  (Figs.  30  and  35).  Its  upper  border  is  the  hyoid 
bone;  its  lower,  after  inclosing  the  brachiocephalic  vein,  passes  on  into 
the  anterior  mediastinum,  becoming  continuous  with  the  pericardium  (see 
Fig.  31).  An  abscess  situated  between  this  layer  and  the  outer  passes 
in  front  of  the  trachea  and  down  to  the  anterior  mediastinum,  causing 
an  abscess  there.  The  deepest  layer  of  the  fascia,  or  prevertebral, 
begins  at  the  transverse  processes  of  the  cervical  vertebrae,  where  it 
is  continuous  with  the  middle  or  previsceral  layer  (Fig.  30).  It  then 
passes  back  of  the  pharynx  and  esophagus,  being  attached  above  to  the 
basilar  process  of  the  occipital  bone  (see  Figs.  30  and  31),  and  laterally 
to  the  transverse  processes  of  the  cervical  vertebrae.  Below,  it  becomes 
continuous  with  the  cellular  tissue  of  the  posterior  mediastinum.  Be- 
tween it  and  the  vertebral  column  there  is  a  space  wider  above  than 
below,  the  retropharyngeal.  It  is  the  seat  of  both  acute  (due  to  lymph- 
glands)  and  chronic  abscesses  (latter  due  to  tuberculosis  of  vertebrae). 
These  abscesses,  unless  opened,  have  a  tendency  to  gravitate  down  be- 
hind the  esophagus  to  the  posterior  mediastinum  (Fig.  31). 

Cut  Throat. — Wounds  resulting  from  suicidal  attempts  are  most 
common  through  the  thyrohyoid  space;  here  the  lingual,  facial,  and 
superior  thyroid  arteries  are  liable  to  be  injured,  and  there  is  also 
danger  of  asphyxia  from  aspirated  blood.  The  next  most  common 
place  is  through  the  trachea,  where  the  vessels  in  the  carotid  sheath 
and  inferior  thyroid  arteries  and  recurrent  laryngeal  nerves  may  be 
injured. 

Air  in  Veins. — Not  infrequently,  during  operations  for  the  removal 
of  tumors  of  the  neck,  especially  those  which  lie  in  close  contact  with  the 
carotid  sheath,  or  in  the  extirpation  of  lymph-glands  which  are  adherent 
to  the  internal  jugular  vein,  the  latter  is  opened  and  air  aspirated.  The 
danger  from  the  entrance  of  air  into  veins  has  been  greatly  exaggerated, 
and  some  of  the  cases  which  were  formerly  supposed  to  have  resulted 
in  death  are  now  believed  to  have  been  cases  of  infection  with  a  gas- 
producing  bacillus.  However,  should  the  air  enter  the  vein,  a  peculiar 
hissing  noise  is  heard  and  the  air  is  aspirated  into  the  ventricles,  causing 
death  through  distention  of  the  right  ventricle. 

Lateral  Region  of  Neck.— This  is  bounded  in  front  by  the  sterno- 
mastoid  muscle;  behind,  by  the  trapezius;  and  below,  by  the  clavicle 
and  acromion.  The  skin  and  subcutaneous  tissue  show  the  same 
characteristics  as  in  the  anterior  region,  except  in  the  upper  part,  where 


136  THE    NECK. 

the  skin  is  thick  and  inelastic  like  that  of  the  posterior  region,  and  is  a 
frequent  seat  of  furuncles.  Such  superficial  abscesses  (boils),  on  account 
of  the  firmness  of  the  connective  tissue,  cause  tense  infiltration  of  the 
latter,  resulting  in  an  almost  board-like  consistency.  Necrosis  of  this  tis- 
sue occurs,  giving  rise  to  the  so-called  "core"  of  these  abscesses  (pseudo- 
carbuncles).  The  fascia  covering  this  region  is  continuous  with  that  of 
anterior  and  posterior  regions,  being  limited  at  the  sternocleidomastoid 
and  trapezius  muscles,  which  it  incloses  (Figs.  30  and  35).  Abscesses, 
e.  £.,  from  the  cervical  vertebrae  situated  under  this  fascia,  are  limited 
in  front  and  behind  by  the  above-mentioned  attachments  to  these  muscles 
and  the  clavicle.  The  lateral  region  corresponds  to  the  posterior  tri- 
angle of  the  neck,  and  has  the  same  boundaries.  The  superficial  layer 
contains  a  large  number  of  lymph-glands,  which  drain  the  ear  and  back 
of  the  head,  and  are  often  the  seat  of  tuberculosis.  In  this  s.ame  layer 
the  external  jugular  vein  can  be  seen  passing  from  the  angle  of  the  jaw 
to  the  middle  of  the  clavicle,  lying  just  beneath  the  skin  and  external 
to  the  fascia  until  just  above  the  clavicle,  where  it  pierces  the  fascia  to 
empty  into  the  subclavian  vein  (see  Figs.  27,  30,  and  35).  At  about 
the  middle  of  the  posterior  border  of  the  sternomastoid  muscle  vari- 
ous nerves  emerge  from  behind  the  muscle  to  pass  across  this  region. 
The  spinal  accessory  emerges  at  this  point  and  crosses  obliquely  to  the 
anterior  border  of  the  trapezius,  entering  it  opposite  the  seventh  cer- 
vical vertebra.  Beginning  from  above  downward,  the  occipitalis  minor 
(see  Figs.  3  and  27)  passes  to  the  back  of  the  head,  supplying  it  with 
sensation.  The  auricularis  magnus  passes  upward  to  the  back  of 
the  ear,  supplying  that  region.  The  superficial  cervical  passes  across 
the  outer  surface  of  the  muscle  to  supply  the  front  of  the  neck.  The 
three  supraclavicular  branches  of  the  superficial  cervical  plexus  pass 
downward  (see  Figs.  21  and  27).  In  caries  of  the  cervical  vertebne 
pain  is  often  referred  to  the  skin  supplied  by  these  nerves.  In  the 
deeper  layer  of  this  region  the  phrenic  nerve  can  be  seen  passing 
parallel  to  the  posterior  border  of  the  sternomastoid,  behind  the  end 
of  the  innominate  vein  into  the  thorax  (best  place  to  apply  electrode 
is  posterior  border  of  sternomastoid).  The  brachial  plexus  passes 
obliquely  down  and  outward,  between  the  scalenus  anticus  and  me- 
dius  muscles  (see  Figs.  28  and  30).  The  subclavian  artery  is  seen 
at  the  lower  part  of  this  region,  crossing  the  first  rib  behind  the 
scalenus  anticus,  while  the  vein  passes  in  front  of  it.  This  is  the 
best  place  to  ligate  or  compress  the  subclavian  artery,  i.  e.,  against 
the  first  rib.  The  thoracic  duct  forms  a  curve  with  convexity 
upward,  just  above  the  middle  of  the  clavicle,  and  empties  a  little 


RELATIONS    AT    LOWER    PART    OF    NECK.  137 

behind  the  posterior  border  of  the  sternomastoid,  at  the  point  of 
junction  of  the  internal  jugular  and  subclavian  veins  (see  Fig.  33). 
In  this  deep  layer,  lying  upon  the  scaleni  muscles  and  brachial  plexus, 
and  beneath  the  sternomastoid,  are  a  number  of  deep  cervical  lymph- 
glands,  which  are  frequently  firmly  adherent  to  the  internal  jugular, 
rendering  it  difficult  to  avoid  injury  to  the  vein  in  their  removal. 
They  bear  a  close  relation  to  the  axillary  glands  and  to  the  mammary 
lymph-vessels,  and  are  of  great  importance  in  malignant  processes  of 
that  organ  (see  Figs.  34  and  54).  They  receive  the  lymph  from  the 
upper  deep  glands,  and,  in  addition,  that  direct  from  the  larynx, 
trachea,  esophagus,  and  thyroid.  The  apex  of  the  pleural  cavity 
lies  beneath  the  subclavian  artery  and  brachial  plexus  (Fig.  30)0 
The  posterior  region  will  be  taken  up  in  the  section  upon  the  Spine. 


138  THE    THORAX. 


THE  THORAX. 

The  bony  thorax  is  formed  by  the  sternum,  ribs,  and  dorsal  verte- 
bras. These  bony  limits  do  not  correspond  with  those  of  the  true  thorax, 
which  is  the  cavity  containing  the  heart,  lungs,  large  blood-vessels,  and 
esophagus.  This  true  thorax  is  bounded  above  by  the  apices  of  the 
pleural  cavity,  around  which  lie  the  vessels,  etc.,  at  the  lower  portion  of 
the  neck  (see  Figs.  33,  35,  36,  37).  Laterally,  it  has  as  its  limits  the  ster- 
num, dorsal  vertebrae,  and  all  of  the  ribs  lying  above  the  attachment  of 
the  diaphragm.  The  latter  muscle  constitutes  the  base  of  the  cone  which 
the  thorax  forms.  The  sides  of  this  cone  are  flattened  in  an  anteroposte- 
rior  direction.  The  apex  of  the  convexity  of  the  diaphragm  is  so  high 
on  each  side  (level  of  fourth  rib  on  right  side,  and  of  fifth  rib  on  left  side) 
that  quite  a  large  proportion  of  the  abdominal  viscera  lie  within  the 
limits  of  the  bony  thorax  (see  Fig.  39).  The  normal  adult  thorax  is 
elliptical  in  shape  on  cross-section  (see  Fig.  40),  being  larger  in  its  trans- 
verse than  in  the  anteroposterior  diameters.  In  the  child  it  is  nearly 
circular  in  outline.  The  best  point  to  measure  the  circumference  of 
the  chest  is  at  the  level  of  the  nipples.  The  shape  of  the  thorax  may 
be  generally  changed,  as  the  result : 

A.  Of  occupation ;  sailors,  shoemakers,  and  carpenters  often  show 
a  marked  depression  at  the  lower  end  of  the  sternum. 

B.  Diseases  of  air-passages. 

(a)  In  emphysema  the  anteroposterior  diameter  tends  to  equal  the 
transverse,  giving  the  chest  a  circular  (reversion  to  infantile  type)  or 
barrel  shape  (Fig.  40). 

(b)  In  tuberculosis;  often  preceding  actual  development  of  disease 
there  is  decrease  of  the  anteroposterior  diameter,  or  flat  chest. 

(c)  Chronic  obstruction  in  the  nose  or  mouth  (adenoids  or  enlarged 
faucial  tonsils) — the  sides  of  the  thorax  are  flattened. 

C.  Spinal  column. 

(a)  In  Pott's  disease  of  the  dorsal  region  the  anteroposterior  diam- 
eter is  frequently  greatly  increased,   and   the  obliquity  of  the   entire 
thorax,  especially  of  the  ribs,  is  so  changed  that  the  latter  often  touch 
the  pelvis  (see  Fig.  152). 

(b)  Lateral  curvature.     This  may  cause  a  change  in  the  diameters, 
so  that  the  anteroposterior  runs  in  an  oblique  direction,  opposite  to  that 
of  the  curvature  (Fig.  40). 

D.  General    disease.     Rickets  may   either  cause  the  sternum   to 
project  (pigeon-breast)  with  flattening  of  the  sides,  or  it  may  cause  a 


139 


CHANGES  IN  SHAPE  OF  THORAX. 


141 


retraction  in  the  transverse  diameter,  giving  a  quadrilateral  aspect  to 
the  chest.  This  is  accompanied  by  prominences  (rachitic  rosary)  at 
the  junction  of  the  costal  cartilages  and  ribs. 

In  addition  to  the  above  bilateral  changes  in  form,  there  may  be  only 
unilateral;  for  example,  the  prominence  over  an  aneurism,  or  the  de- 


Fig.  40. — Cross-sections  (diagrammatic)  of  normal  and  pathologic  chests,  i, 
Normal  chest.  Anteroposterior  diameter  (AP)  less  than  transverse.  On  the  right  side 
of  the  thorax  the  distribution  of  a  typical  intercostal  nerve  is  shown  with  its  three 
branches,  posterior  (S),  lateral  (L),  and  anterior  (F).  The  relation  to  the  sympa- 
thetic is  shown.  VG,  Vertebral  ganglion.  PVG,  Prevertebral  ganglion.  Upon  the  left 
side  of  the  thorax  the  distribution  of  a  typical  intercostal  artery  is  shown.  D,  Descending 
or  thoracic  aorta.  S,  Posterior.  L,  Lateral,  and  F,  Anterior  branches  of  the  anterior 
and  posterior  intercostal  arteries,  the  anterior  being  derived  from  the  internal  mammary, 
near  F.  2,  Emphysematous  chest.  On  account  of  its  barrel-shape  the  anteroposterior 
almost  equals  the  transverse  diameter.  3,  Rachitic  or  pigeon-breast.  Anteroposterior 
greater  than  the  lateral  diameter.  4,  Flat  or  tubercular  chest.  Anteroposterior  much 
less  than  the  lateral  diameter.  5,  Scoliotic  chest.  Diameters  are  oblique. 


formity  of  the  chest  following  hypertrophy  of  the  heart  in  young  people, 
there  being  a  decided  prominence  over  the  region  of  the  heart.  On 
the  other  hand,  the  entire  side  may  be  more  prominent,  as  the  result  of 
contraction  of  the  opposite  lung. 

In  the  examination  of  the  thorax  in  the  living,  the  following 
points  are  to  be  noted: 


142  THE    THORAX. 

1.  Palpate  the  sternum,  beginning  with  the  notch  known  as  the 
suprasternal,   situated  between  the  two  clavicles;  passing  downward 
along  the  sternum,  one  can  feel  a  prominence  which  is  an  important 
landmark  in  counting  the  ribs.     This  is  situated  at  the  junction  of  the 
manubrium  and  gladiolus,  and  corresponds  to  the  level  of  the  second 
costal  cartilage  and  rib.     At  the  lower  end  of  the  sternum  palpate  the 
xiphoid  cartilage.     It  is  often  bent  inward,  as  the  result  of  occupation, 
or  may  be  curved  outward,  causing  it  to  become  quite  prominent. 

2.  Palpate  the  ribs.    This  can  be  done  quite  easily,  except  in  fat  indi- 
viduals.    The  first  rib  lies  so  deeply  under  the  clavicle  that  it  can  only 
be  felt  behind  the  latter.     Here  the  pulsations  of  the  subclavian  artery 
can  be  detected.     The  remaining  ribs  can  be  readily  felt,  except  the  last 
two  floating  ribs,  for  which  it  is  necessary  to  palpate  deeply  and  close  to 
the  spine.     Note  the  obliquity  of  the  ribs,  and  that  the  lower  end  of  the 
rib  in  front  is  considerably  below  its  level  at  the  spine.     In  children  it 
is  of  great  importance  to  palpate  at  the  junction  of  the  ribs  and  costal 
cartilages,  so  as  to  become  accustomed  to  the  normal  prominence,  as 
distinguished  from  the  rachitic  enlargement  at  this  point. 

3.  Palpate  the  breasts.     In  the  male  they  are  quite  rudimentary; 
in  the  female  they  extend  from  the  third  to  the  seventh  ribs.     The 
nipple  lies  in  the  fourth  intercostal  space,  in  a  line  drawn  from  the  middle 
of  the  clavicle  downward. 

4.  Palpate  the  chief  muscle  of  the  thorax,  the  pectoralis  major, 
whose  lower  margin,  as  it  slopes  upward  to  form  the  anterior  wall  of  the 
axilla,  can  be  rendered  quite  prominent  by  bringing  the  arm  to  the  side 
of  the  chest.     In  the  same  manner,  palpate  the  corresponding  muscle 
on  the  back  of  the  chest,  which  forms  the  posterior  wall  of  the  axilla, 
the-latissimus  dorsi. 

5.  When  the  patient's  arm  is  brought  up  toward  the  head,  note  the 
serrations  of  the  serratus  magnus  on  the  side  of  the  chest. 

6.  Palpate  the  coracoid  process,  just  below  the  outer  end  of  the 
clavicle.     Also  the  sternoclavicular  and  acromioclavicular  joints. 

7.  Palpate  the  apex-beat,  and  note  its  position  just  inside  of  the 
midclavicular  line  in  the  fifth  intercostal  space.     In  children  it  is  gen- 
erally situated  in  the  fourth  intercostal  space. 

For  the  sake  of  convenience  certain  lines  are  used  in  order  to  locate 
the  organs,  etc.,  contained  in  the  thorax  (see  Fig.  41). 

1.  Sternal  line.     Drawn  vertically  through  middle  of  sternum. 

2.  Lateral  sternal  lines.     Drawn  through  sides  of  sternum. 

3.  Parasternal  line.     Drawn  midway  between  the  lateral  sternal  and 
mammary  lines. 


Fig.  41. — Surface  markings  of  pleura,  lungs,  pericardium,  and  fissures  of  lungs;  also 
divisions  of  abdomen.  S,  Sternal  line.  LS,  Lateral  sternal  line.  PS,  Parasternal  line. 
MC,  Midclavicular  line.  1C,  Infraclavicular  region.  MR,  Mammary  region.  M, 
Transverse  mammary  line.  PL,  Pleura,  crossing  midclavicular  line  at  seventh  rib.  Its 
relation  to  the  pericardium  should  be  noted.  L,  Surface  outline  of  lungs  following  closely 
that  of  pleura.  It  crosses  the  sixth  rib  at  the  midclavicular  line.  P,  Pericardium  outlined. 
Its  relation  to  the  pleura  should  be  followed.  D,  Diaphragm.  The  interlobar  fissures 
are  seen  upon  the  right  and  left  sides,  showing  that  upon  the  right  side  the  right  upper, 
middle,  and  lower  lobes  come  to  the  surface  of  the  chest;  upon  the  left  side  the  left  upper 
and  lower.  RH,  Right  hypochondriac  region.  EP,  Epigastric  region.  LH,  Left  hypo- 
chondriac region.  RL,  Right  lumbar  region.  UM,  Umbilical  region.  LL,  Left  lumbar 
region.  RI,  Right  iliac  region.  HY,  Hypogastric  region.  LI,  Left  iliac  region. 


SURFACE    MARKINGS    OF    THE    THORACIC    ORGANS.  145 

4.  Mammary  or  midclavicular  lines.     Drawn  vertically  through  nip- 
ples from  middle  of  clavicle. 

5.  Axillary  line.     Drawn  vertically  from  apex  of  axilla  down. 

6.  Scapular  line.     Drawn  vertically  through  angle  of  scapula. 

7.  Anterior  axillary  line.     Drawn  from  junction  of  pectoralis  major 
and  axilla  downward. 

8.  Posterior  axillary  line.     Drawn  from  junction  of  axilla  and  latis- 
simus  dorsi  downward. 

That  portion  of  the  thorax  which  lies  above  the  clavicle  in  front  is 
called  the  supraclavicular  region ;  that  below  the  clavicle  as  far  as  the  third 
rib  is  called  the  infraclavicular  region  or  fossa.  From  the  third  to  the  sixth 
ribs  is  called  the  mammary  region.  The  region  below  the  sixth  rib  is 
called  the  inframammary  region.  In  the  axillary  line  we  have,  from 
the  apex  of  the  axilla  to  the  sixth  rib,  the  axillary  region ;  from  that  point 
down,  the  infra- axillary  region  .  Above  the  spine  of  the  scapula  is  the 
suprascapular  region.  Below  the  spine  of  the  scapula  is  the  infra- 
scapular,  and  between  the  vertebral  borders  of  the  two  scapulae,  the 
interscapular  region. 

Surface  Markings  of  the  Thoracic  Organs.* 

Pleurae. — Beginning  at  the  sternoclavicular  joint  on  each  side,  the 
surface  markings  of  the  pleura  correspond  to  a  line  drawn  from  each 
sternoclavicular  joint  to  the  prominence  at  the  junction  of  the  first  and 
second  portions  of  the  sternum  (see  Fig.  41).  The  two  pleurae  then  run 
parallel  to  each  other,  the  right  passing  a  little  beyond  the  median  line. 
The  space  between  them  corresponds  to  the  location  of  the  anterior  medi- 
astinum. At  the  fourth  rib  the  left  pleura  leaves  the  sternum  and  passes 
outward  in  an  oblique  manner,  following  the  left  border  of  the  sternum 
to  the  sixth  costal  cartilage.  The  space  thus  left  between  it  and  the 
sternum  corresponds  to  that  portion  of  the  pericardium  which  is  in 
contact  with  the  chest-wall.  On  the  right  side  the  pleura  continues 
almost  to  the  ensiform  process,  and  then  passes  gradually  outward, 
crossing  the  lower  border  of  the  seventh  rib  in  the  mammary  line,  the 
ninth  rib  in  the  axillary,  and  the  eleventh  near  the  spine  (see  Figs.  41, 
42,  43,  and  44). 

The  upper  markings  of  the  pleura  are  a  line  drawn  obliquely  upward 
and  outward  from  the  sternoclavicular  joint  across  the  lower  portion 
of  the  neck,  in  such  a  manner  as  to  curve  upward,  and  reach  the  spine 
at  the  level  of  the  vertebra  prominens.  The  highest  point  of  this 

*  The  student  is  advised  to  outline  these  surface  markings  under  the  supervision  of  the 
instructor. 


146  THE    THORAX. 

curve  is  an  inch  and  a  half  above  the  clavicle.  This  corresponds  to 
the  apex  of  the  pleural  cavity.  Posteriorly,  both  pleurae  (see  Fig.  42) 
follow  close  to  the  spinal  column  from  the  vertebra  prominens  to  the 
eleventh  rib  below,  curving  downward  and  outward  so  as  to  extend 
almost  to  the  tip  of  the  twelfth  rib.  (See  Abdomen.) 

Lungs. — The  surface  markings  of  the  lungs  correspond  closely  to 
those  of  the  pleura,  above  and  in  the  median  line,  both  on  the  left  and 
right  sides.  The  only  difference  is  that  the  lower  borders  of  both  lungs 
are  the  sixth  rib  in  the  mammary  line,  the  eighth  rib  in  the  axillary,  and 
the  tenth  rib  behind  (see  Figs.  41,  42,  43,  and  44).  The  interval  between 
the  lower  surface  markings  of  the  lungs  and  pleurae  corresponds  to  the 
complementary  space  or  sinus  of  the  pleura.  During  inspiration  the 
lower  margins  of  the  lung  move  downward  almost  as  far  as  the  above- 
mentioned  lower  limits  of  the  pleurae;  namely,  seventh  rib  in  the  mam- 
mary line,  ninth  rib  in  the  axillary,  and  eleventh  rib  posteriorly.  In 
marking  the  normal  chest,  it  is  advisable  to  let  the  patient  take  a  deep 
breath,  and  note  by  percussion  this  respiratory  excursion  of  the  lung. 

The  lower  surface  markings  of  the  pleura  correspond  to  the  inser- 
tions of  the  diaphragm  into  the  chest-wall. 

Trachea  and  Bronchi. — The  tracheal  surface  marking  corresponds 
to  a  broad  line  (Figs.  41  and  45)  drawn  from  the  upper  margin  of  the 
sternum  to  the  level  of  the  second  rib  in  the  median  line.  At  this  point 
the  trachea  divides  into  the  two  main  bronchi,  the  right  and  the  left, 
the  surface  markings  of  which  correspond  to  a  line  passing  downward 
and  outward  from  this  point . 

Aorta. — The  aorta  corresponds  to  a  line  drawn  from  the  junction 
of  the  third  left  costal  cartilage  and  sternum  to  the  upper  border  of  the 
second  costal  cartilage  on  the  right  side.  It  then  crosses  obliquely 
(Fig.  36)  in  the  median  plane  of  the  chest,  to  reach  the  vertebral  column 
on  the  left  side  of  the  upper  dorsal  vertebra  (Fig.  42). 

The  pulmonary  artery  corresponds  to  a  line  drawn  from  the  second 
left  intercostal  space  to  the  second  left  costal  cartilage,  where  it  bifur- 
cates (Fig.  45).  The  right  ventricle  under  normal  conditions  is  the  only 
portion  of  the  heart  in  immediate  contact  with  the  chest-wall.  Only 
the  edge  of  the  left  ventricle  is  visible.  The  pulmonary  orifice  is  oppo- 
site the  junction  of  the  third  left  costal  cartilage  with  the  sternum;  a 
little  lower  are  the  aortic  valves  (see  Fig.  45).  The  mitral  and  tri- 
cuspid  valves  lie  almost  under  the  fourth  intercostal  space,  close  to  the 
left  border  of  the  sternum,  the  tricuspid  lying  behind  the  sternum  a 
little  lower. 

Interlobar  Fissures. — The  surface  marking  of  the  fissure  between 


Fig.  42. — Surface  markings  of  pleurae,  lungs,  interlobar  fissures,  and  relations  of  the 
pleural  cavity  to  kidneys,  i,  Apical  and  mediastinal  pleura.  2,  Upper  and  posterior 
margins  of  lungs.  3,  Interlobar  fissures  between  upper  and  lower  lobes  on  both  sides. 
4,  Lower  border  of  lung.  5,  Lower  border  of  pleura.  6,  Left  kidney.  7,  Right  kidney. 
Upon  the  right  side  observe  a  short  twelfth  rib,  as  not  infrequently  occurs,  lying  entirely 
within  the  pleural  cavity.  Upon  the  left  side  the  ribs  are  shown  in  the  normal  or  average 
length  (see  text).  8,  Ascending  colon.  9,  Transverse  colon.  10,  Descending  colon, 
n,  Iliac  colon.  12,  Pelvic  colon — n  and  12  are  usually  described  together  as  the  sigmoid 
flexure.  13,  Rectum  and  anal  canal.  The  extraperitoneal  portions  of  the  ascending 
and  descending  colon  and  rectum  are  represented  by  the  finely  dotted  areas.  DS,  Left 
dome  of  diaphragm.  DR,  Right  dome  of  diaphragm.  SP,  Spleen.  14,  Cecum.  15, 
Beginning  of  ileum.  16,  Appendix. 


147 


Fig.  43. — Surface  markings  of  thoracic  and  abdominal  viscera  viewed  from  the  left 
side;  also  view  of  Roser-Nelaton  line.  C.C.,  Costo-clavicular  line.  Ax,  Mid-axillary  line. 
U.L.,  Upper  lobe  of  lung.  L.L.,  Lower  lobe.  2,  Lower  margin  of  lung.  3,  Lower  margin 
of  pleura.  4,  Anterior  superior  spine  of  ilium.  5,  Costal  arch.  S,  Spleen.  T.C.,  Trans- 
verse colon.  D.C.,  Descending  colon.  S.F.,  Sigmoid  flexure  (iliac  colon).  R.N.,  Roser- 
Nelaton  line  passing  from  4  across  top  of  trochanter  major  (T)  to  tuberosity  of  ischium 
(Is.). 


149 


Fig.  44. — Surface  markings  of  thoracic  and  abdominal  viscera  (right  side).  U.L., 
Right  upper  lobe  of  lung.  L.L.,  Right  lower  lobe.  M.L.,  Middle  lobe,  i,  Upper  border 
of  liver.  7,  Lower  border  of  liver.  2,  Lower  border  of  lung.  3,  Lower  border  of  pleura. 
4,  Fissure  between  right  lower  and  middle  lobes.  5,  Fissure  between  right  upper  and  middle 
lobes.  6,  Gall-bladder.  T.C.,  Transverse  colon.  A.C.,  Ascending  colon.  A.Sp., 
Anterior  superior  spine  of  ilium.  Ax,  Mid-axillary  line. 


SURFACE    MARKINGS    OF    THE    THORACIC    ORGANS.  153 

the  upper  and  lower  lobes  of  the  right  lung  is  a  line  drawn  from  the 
third  dorsal  spine  obliquely  downward  in  such  a  manner  as  to  reach 
the  sixth  rib  close  to  the  midclavicular  line  (Figs.  41  and  42). 

That  between  the  upper  and  lower  lobes  on  the  left  side  is  exactly 
the  same.  On  the  right  side,  as  this  interlobar  fissure  between  the  right 
upper  and  lower  lobes  passes  forward,  it  forms  the  boundary-line  from 
the  posterior  axillary  line  onward,  between  the  middle  and  lower  lobes 
(see  Fig.  44).  The  interlobar  fissure  between  the  upper  and  middle 
lobes  of  the  right  lung  corresponds  to  a  line  drawn  from  the  apex  of  the 
axilla  almost  horizontally  to  the  sternum,  reaching  the  latter  at  about 
the  level  of  the  fourth  costal  cartilage  (see  Fig.  41).  In  accordance  with 
the  course  of  these  interlobar  fissures,  the  following  lobes  of  the  lung 
are  in  relation  with  the  chest-wall.  Anteriorly,  on  the  right  side,  the 
upper,  middle,  and  lower  lobes.  On  the  left  side,  upper  and  lower  lobes 
(Fig.  41).  In  the  axilla  on  the  right  side,  middle  and  lower  lobes  (Fig. 
44).  On  the  left  side,  upper  and  lower  lobes  (Fig.  43).  Posteriorly, 
only  the  upper  and  lower  lobes  of  both  lungs  are  in  relation  to  the  chest- 
wall  (Fig.  42). 

Pericardium. — The  upper  border  of  the  surface  marking  of  the 
pericardium  corresponds  to  the  junction  of  the  first  and  second  portions 
of  the  sternum;  that  is,  the  level  of  the  second  rib  (Fig.  41).  It  then 
passes  to  the  right  almost  as  far  as  the  parasternal  line,  and  to  the  left 
in  an  oblique  manner  toward  the  midclavicular  line  and  apex  of  the 
heart.  It  is  somewhat  elliptical  in  shape,  a  portion  coming  in  direct 
contact  with  the  diaphragm  just  behind  the  ensiform  process  and  fifth 
costal  cartilage  on  the  left  side. 

The  skin  of  the  thorax  is  thicker  than  that  of  the  face  and  neck.  It 
is  loosely  attached,  except  over  the  sternum.  In  its  upper  part  are  many 
sebaceous  glands,  which  are  frequently  the  seat  of  an  acne.  The  sub- 
cutaneous tissue  over  the  front  and  side  has  a  loose-meshed  structure; 
over  the  back,  a  much  firmer  and  closer.  Hence,  subcutaneous 
phlegmons  spread  rapidly  through  the  former.  It  contains  a  consider- 
able amount  of  fat,  especially  over  the  pectoral  muscles.  Lipomata 
not  infrequently  develop  in  this  fat  over  the  back  of  the  thorax.  The 
principal  muscles  are  (i)  the  pectoralis  major,  which  arises  from  the 
sides  of  the  sternum,  and  the  upper  six  costal  cartilages  (sternal  portion), 
and  also  from  the  inner  end  of  the  clavicle  (clavicular  portion),  and 
passes  across  to  the  upper  portion  of  thehumerus;  (2)  the  pectoralis 
minor;  (3)  the  serratus  magnus;  (4)  the  latissimus  dorsi;  (5)  the  exter- 
nal and  internal  intercostals. 

10 


154  THE    THORAX. 

Between  the  pectoralis  major  and  the  deltoid,  just  below  the  outer 
end  of  the  clavicle,  is  a  depression  (Mohrenheim's  fossa),  in  which  can 
be  found  superficially  the  cephalic  vein  and  the  acromiothoracic  artery 
(see  Fig.  94).  This  muscle  (pectoralis  major)  is  covered  by  a  fascia  called 
the  deep  pectoral  fascia  (see  Figs.  46  and  47),  separating  it  from  the  over- 
lying mammary  gland.  It  is  often  involved  in  carcinoma  of  the  organ, 
and  should  be  stripped  from  the  muscle  in  the  amputation  of  the  breast. 
Beneath  this  muscle  lies  the  smaller  pectoral  muscle  (minor),  attached 
to  the  coracoid  process  (Figs.  46  and  47).  It  is  also  covered  by  a  firm 
fascia,  continuous  with  the  middle  layer  of  the  deep  cervical  fascia,  and 
called  the  costacoracoid  membrane.  It  incloses  the  muscle  in  a  sheath, 
and  then  passes  outward  to  form  a  covering  for  the  axillary  vessels. 
Suppuration  beneath  this  layer  of  fascia  is  apt  to  extend  upward  into 
the  neck  (see  Fig.  31).  Beneath  it — /.  c.,  under  the  pectoralis  minor 
muscle,  just  below  its  attachment  to  the  coracoid  (Fig.  94) — lie  the  sub- 
clavian  vein  and  artery,  the  former  lying  in  front.  The  brachial  plexus 
also  lies  in  front  of  the  artery.  As  will  be  referred  to  later,  the  head  of 
the  humerus  in  subcoracoid  dislocation  rests  upon  the  vessels  and  nerves 
here  (see  Fig.  92). 

The  pectoralis  major  forms  the  anterior  border  of  the  axilla,  the 
latissimus  dorsi  (arising  from  the  back  of  the  lower  thorax,  to  be  in- 
serted into  the  upper  end  of  humerus)  forms  the  posterior  wall.  The 
serratus  magnus  lies  on  the  lateral  aspect  of  the  chest,  and  is  crossed  in 
a  vertical  direction  by  the  long  thoracic  artery  and  nerve  (external  res- 
piratory nerve  of  Bell),  both  of  which  may  be  cut  in  removal  of  the 
axillary  glands  in  amputation  of  the  breast.  The  cutting  of  this 
nerve  results  in  a  paralysis  of  the  serratus  magnus  supplied  by  it  (see 
Figs.  46  and  47).  The  serratus  magnus  has  as  its  function  the  fixation 
of  the  scapula  when  the  arm  is  raised ;  hence,  when  the  nerve  is  para- 
lyzed, there  is  no  point  of  fixation  for  the  scapula,  and  the  arm  is  raised 
with  difficulty. 

Covering  the  intercostal  spaces,  as  well  as  the  ribs,  is  the  continua- 
tion of  the  costacoracoid  fascia.  Beneath  it  in  each  space  lie  the  inter- 
costal muscles,  the  internal  extending  from  the  sternum  to  the  angle  of 
the  ribs,  the  external  from  the  spine  to  the  costal  cartilages ;  the  former 
being  attached  to  the  inner  margin  of  adjacent  ribs,  the  latter  to  the 
outer.  They  are  separated  from  each  other  by  a  layer  of  fascia,  and  the 
internal  is  separated  from  the  pleura  by  another  firm  layer  of  fascia, 
the  endothoracic.  Abscesses  arising  from  the  ribs  can  only  with  diffi- 
culty pass  inward  (see  Fig.  40)  on  account  of  this  firm  fascia. 

Similarly,  abscesses  arising  from  the  bodies  of  the  vertebra  can  only 


Fig.  45. — View  of  heart  and  large  blood-vessels  of  thorax  and  neck  in  adult,  i, 
Upper  border  of  thyroid  cartilage,  opposite  which  the  common  carotid  divides  into  the 
internal  and  external  carotid  arteries.  2,  Common  carotid  artery.  3,  Internal  jugular  vein. 
4,  External  jugular  vein.  5,  Upper  rings  of  trachea.  6,  Subclavian  artery.  7,  Subclavian 
vein.  8,  Arch  of  aorta.  9,  Superior  vena  cava.  10,  Lateral  lobes  of  thyroid  gland. 
R.B.,  Right  bronchus.  L.B.,  Left  bronchus.  P,  Pulmonary  artery,  xxx,  Tricuspid 
valve.  A,  Aortic  valve.  M,  Mitral  valves.  The  arrow  passing  up  the  aorta  shows  the 
direction  in  which  aortic  murmurs  are  transmitted.  The  arrow  beginning  at  M,  and 
directed  toward  the  apex  of  the  heart,  shows  the  direction  in  which  mitral  murmurs  are 
transmitted.  P,  Position  of  pulmonary  valve. 


155 


Fig.  46. — Horizontal  section  of  thorax  through  third  dorsal  vertebra.  In  the  illus- 
tration the  black  space  indicating  the  pleural  cavity  is  artificial,  and  due  to  the  contraction 
of  the  lung  toward  its  root,  and  away  from  the  chest-wall,  after  death.  During  life  the 
visceral  and  parietal  pleurae  would  be  in  apposition.  RUL,  Right  upper  lobe  of  lung. 
RLL,  Right  lower  lobe.  LUL,  Left  upper  lobe.  LLL,  Left  lower  lobe.  An  interlobar  fis- 
sure is  seen  on  each  side.  P,  Pleural  cavity.  Under  normal  conditions,  during  life,  such  a 
cavity  does  not  exist,  the  parietal  and  visceral  pleurae  being  in  direct  contact.  AA,  Ascend- 
ing portion  of  arch  of  aorta.  DA,  Descending  portion  of  arch  of  the  aorta.  N,  Phrenic 
nerve,  i,  Pulmonary  artery.  2,  Right  and  left  bronchus.  3,  Pulmonary  vein.  4, 
Esophagus,  on  either  side  of  which  is  seen  as  a  white  dot  the  vagus  nerve,  and  to  the  left 
of  the  esophagus,  close  to  the  spinal  column,  the  thoracic  duct.  Behind  the  descending 
arch  of  the  aorta  the  sympathetic  is  seen  as  a  white  dot.  5,  Internal  mammary  vessels, 
at  this  level  lying  close  to  edges  of  sternum.  6,  Pectoralis  major  muscle.  7,  Pectoralis 
minor  muscle.  8,  Long  thoracic  artery  and  nerve.  9,  Teres  minor  muscle.  10,  Infra- 
spinatus. 


157 


Fig.  47. — Horizontal  section  of  thorax  through  ninth  dorsal  vertebra  (fourth  rib), 
showing  relations  of  lungs,  pleura,  pericardium,  and  heart.  The  section  also  shows  the 
female  breast  displaced  further  toward  the  axilla  than  is  normal,  due  to  the  mode  of 
preparation  (formalin).  The  black  space  indicating  the  pleural  and  pericardial  cavities 
does  not  exist  during  life,  as  was  explained  in  Fig.  46.  LL,  Left  lower  lobe.  RL,  Right 
lower  lobe.  P,  Pleural  cavity;  under  normal  conditions,  this  does  not  exist  during  life. 
RV,  Right  ventricle.  LV,  Left  ventricle.  LA,  Left  auricle.  Between  the  two  is  seen 
one  of  the  mitral  valves.  RA,  Right  auricle,  i,  Phrenic  nerve,  placed  in  connective 
tissue  between  mediastinal  pleura  and  parietal  pericardium.  2,  Descending  or  thoracic 
aorta.  3,  Vagus  nerves.  Between  the  two  is  seen  the  esophagus  as  a  flat  black  area.  5, 
Thoracic  duct.  4,  Sympathetic  nerves.  The  black  dot  anterior  to  each  represents  the 
venae  azygos.  6,  Pectoralis  major,  covered  by  pectoral  fascia.  Beneath  it  is  seen  the 
pectoralis  minor.  M,  Mammary  gland,  showing  radiating  arrangement  of  milk-duct 
toward  nipple.  It  is  placed  nearer  the  axilla  than  is  normal,  the  section  having  been  made 
on  a  formalinized  cadaver. 


159 


Fig.  48. — Surface  markings  of  principal  veins  on  anterior  surface  of  body,  i,  Ante- 
rior intercostal  veins,  which  arise  from  the  internal  mammary.  2,  Continuation  of  the 
anterior  intercostal  veins,  which  join  with  the  posterior  intercostals,  having  their  origin  in 
the  azygos  veins.  3,  Terminal  branches  of  internal  mammary,  forming  the  superior 
epigastric  veins.  4,  Superficial  inferior  epigastric  vein.  5,  Deep  inferior  epigastric  vein. 
6,  External  iliac  veins.  7,  Femoral  vein.  The  dotted  portion  below  shows  the  popliteal 
vein  as  projected  on  the  anterior  surface  of  the  thigh.  8,  Internal  saphenous  vein,  empty- 
ing into  the  femoral  vein  at  the  saphenous  opening.  9,  Cephalic  vein,  joining  with  10, 
the  basilic  vein,  to  empty  into  the  subclavian.  n,  Median  basilic  vein,  which  is  most 
often  chosen  for  intravenous  transfusion  or  venesection.  12,  Median  cephalic  vein. 
R,  Radial  vein.  M,  Median  vein.  U,  Ulnar  vein. 

161 


THE    THORAX.  163 

pass  downward,  the  endothoracic  fascia  limfting  their  passage  outward, 
being  attached  to  the  transverse  processes  of  the  vertebrae. 

Between  the  intercostal  muscles,  and  furnishing  them  with  nerve- 
and  blood-supply,  lie  the  corresponding  arteries  and  nerves  in  a  groove 
on  the  inferior  surface  of  each.  The  nerves  and  arteries  perforate  the 
muscles  close  to  the  spine  (at  angle  of  ribs),  in  the  axillary  and  para- 
sternal  lines  to  reach  the  skin,  and  over  these  points  there  is  exquisite 
sensitiveness  in  intercostal  neuralgia  (see  Figs.  40,  48,  and  49).  The 
superficial  and  deep  arteries  are  derived  in  front  from  the  internal 
mammary  artery  (which  runs  between  the  endothoracic  fascia  and  ribs, 
i  cm.  on  each  side  of  the  sternum).  It  is  derived  from  the  subclavian 
and  gives  off  an  anterior  intercostal  branch  (Fig.  50).  Laterally  and 
behind,  the  thoracic  wall  is  supplied  by  the  intercostal  arteries  arising 
from  the  thoracic  aorta,  from  which  arise  perforating  branches  for 
the  skin  and  intercostal  muscles,  the  anterior  and  posterior  vessels 
joining  with  each  other.  The  pectoral  muscles  are  supplied  by  the 
acromiothoracic  branch  of  the  axillary.  These  arteries  anastomose 
with  the  superficial  and  deep  inferior  epigastric  branches,  and  in  case 
of  obstruction  in  the  aorta — e.  g.,  mediastinal  tumor — establish  a  col- 
lateral circulation  (see  Fig.  50). 

Stab  wounds  of  the  internal  mammary  artery  may  give  rise  to  severe 
hemorrhage,  causing  hemothorax  and  even  death,  through  compression 
of  the  heart  and  lungs. 

The  veins,  both  superficial  and  deep,  accompany  the  arteries,  the 
superficial  veins  emptying  into  the  external  jugular  above  and  the  super- 
ficial epigastric  below  (Fig.  48).  The  deep  veins  empty  into  the  subclavian 
in  front  through  veins  accompanying  the  internal  mammary  artery.  On 
the  right  side  the  posterior  intercostal  veins  empty  into  the  great  azygos 
vein,  lying  to  the  right  of  the  vertebral  column  within  the  thorax  (Fig. 
51).  On  the  left  side  the  four  lower  posterior  intercostals  empty  into 
the  vena  hemiazygos  inferior,  which  empties  into  the  vena  azygos  by 
passing  across  the  front  of  the  vertebral  column. 

In  obstruction  of  the  portal  circulation  the  anastomoses  of  the 
superficial  and  deep  veins  of  the  thorax  with  the  branches  of  the  epi- 
gastric veins  (emptying  into  the  iliac  veins)  cause  a  collateral  circulation 
to  be  established  between  the  latter  and  the  subclavian  (receiving  deep 
mammary)  and  superior  vena  cava,  into  which  the  great  azygos  (re- 
ceiving posterior  intercostals)  empties  (Fig.  50).  In  tumors  of  the 
mediastinum,  or  in  aneurism  pressing  upon  the  venae  cavae,  there  is 
enormous  dilatation  of  the  superficial  veins  emptying  into  the  internal 
jugular  and  subclavian  veins  (collateral  circulation). 


164  THE    THORAX. 

The  nerves  are  derived  from  the  intercostal  nerves  (the  points  at 
which  the  perforating  branches  occur  are  at  the  angle  of  the  ribs  behind, 
in  the  axillary  and  parasternal  lines,  and  over  these  points  there  is 
exquisite  sensitiveness  in  intercostal  neuralgia)  (Figs.  40  and  49). 

The  second  intercostal  nerve  joins  with  a  branch  of  the  internal 
cutaneous  derived  from  the  brachial  plexus,  forming  the  intercosto- 
humeral  nerve  (Fig.  49).  Pain  along  this  nerve  is  referred  down  the 
arm.  The  nerve  is  frequently  affected  in  a  condition  known  as 
angina  pectoris.  On  account  of  the  close  relation  with  the  sympathetic 
nerves,  pain  due  to  disease  in  other  organs — e.  g.,  the  stomach — is  often 
referred  along  the  intercostal  nerves,  especially  the  sixth  on  the  left  side 
(Fig  49;  also  see  Abdomen). 

Herpes  zoster  occurs  on  the  skin  of  the  thorax.  The  distribution 
of  the  vesicles  and  pain  corresponds  accurately  to  that  of  an  intercostal 
nerve.  The  intercostal  nerves,  arteries,  and  veins  each  lie  in  a  groove 
on  the  under  surface  of  the  ribs,  external  to  the  periosteum;  so  that 
when  the  rib  is  resected,  is  it  necessary  to  incise  the  periosteum  and 
free  the  rib  entirely  from  its  periosteum  before  cutting  it,  in  order  to 
avoid  these  structures. 

The  lymphatics  of  the  surface,  including  those  of  the  breast,  empty 
chiefly  into  the  axillary  glands,  although  some  empty  into  the  deep  cervical 
glands  of  the  posterior  triangle  (see  Figs.  52  and  53).  They  do  not 
anastomose  with  the  deeper  ones  which  lie  beneath  each  intercostal 
muscle,  the  outer  emptying  into  a  set  of  lymph-glands  accompanying 
the  internal  mammary  artery;  the  inner  into  the  thoracic  duct  on  the 
left  and  the  right  lymphatic  trunk  on  the  right  side. 

Fractures  of  the  sternum  are  rare.  They  are  usually  due  to  direct 
violence,  and  are  found  near  the  junction  of  its  first  and  second  portions. 
The  upper  fragment  is  displaced  behind  the  lower.  The  displacement, 
attitude  of  patient  with  body  bent  forward,  and  localized  area  of  pain 
aid  in  making  a  diagnosis.  This  fracture  may  be  accompanied  by 
injury  to  the  heart  and  lungs. 

Fractures  of  the  ribs  are  almost  always  due  to  direct  vio- 
lence. On  account  of  the  great  elasticity  of  the  ribs  in  children, 
they  are  rare  at  that  age.  They  are  most  frequent  in  the  third 
to  ninth  ribs  at  the  greatest  convexity,  although  a  fracture  through 
the  articulation  with  the  costal  cartilages  is  not  rare.  A  false  point  of 
motion  can  almost  always  be  elicited,  the  displacement  being  minimal. 
Crepitus  cannot  always  be  obtained,  although  frequently  felt  by  the 
patient.  The  fracture  is  frequently  accompanied  by  a  dry  pleurisy. 
This  is  due  to  the  close  relation  of  the  parietal  pleura  to  the  inner 


Fig.  49. — Anterior  view  of  the  areas  of  distribution  of  the  sensory  nerves  of  the  skin  (shown  on 
the  left  side  of  the  body),  and  distribution  of  sensation  according  to  segments  of  the  spinal  cord 
(shown  on  the  right  side  of  the  body),  i,  Ophthalmic  nerve.  2,  Superior  maxillary  nerve.  3,  In- 
ferior maxillary  nerve.  The  points  of  exit  of  the  supra-orbital,  infra-orbital,  and  mental  nerves  are 
shown  by  the  markings  X.  4,  Points  of  exit  of  the  anterior  intercostal  branches  of  the  intercostal 
nerves.  5,  Points  of  exit  of  the  lateral  branches  of  the  intercostal  nerves.  6,  Intercosto-humeral 
nerve.  A.M.  and  S.C.,  Area  of  distribution  of  the  great  auricular,  superficial  cervical,  and  supra- 
clavicular  branches  of  the  cervical  plexus.  C,  Circumflex  nerve.  W,  Nerve  of  Wrisberg.  I.C.,  In- 
ternal cutaneous  area.  M.S.,  Musculospiral  area.  M.C.,  Musculocutaneous  area.  U,  Dinar.  M, 
Median.  R,  Radial.  G.C.,  Genitocrural  area.  The  nerve  is  seen  as  distributing  its  branches  to  the 
genital  region  and  to  the  upper  portion  of  the  thigh.  E.G.,  External  cutaneous  area.  1. 1.,  Ilio-in- 
guinal  area.  I.C.U.,  Internal  cutaneous  area  of  the  thigh.  M.C.U.,  Middle  cutaneous  of  thigh.  I.S., 
Internal  saphenous.  P,  External  popliteal  branches  area.  On  the  right  side  the  division  according 
to  segments  is  seen,  the  letters  C,  D,  L,  and  S  standing  respectively  for  cervical,  dorsal,  lumbar,  and 
sacral  segments  of  the  cord.  On  the  right  side,  from  the  fourth  dorsal  to  the  twelfth  dorsal  (inclu- 
sive), the  maximum  points,  according  to  Head,  of  the  abdominal  viscera  are  shown  in  relation  to  the 
spinal  segments.  (See  Abdomen.) 

I65 


Fig.  50. — Veins  of  surface  of  chest  and  abdomen  to  show  establishment  of  collateral 
circulation  in  cirrhosis  of  liver  or  mediastinal  tumors,  i,  Internal  mammary  veins.  2, 
Anterior  intercostal  veins,  anastomosing  with  posterior  intercostals.  3,  Posterior  inter- 
costals,  anastomosing  with  anterior  intercostals.  4,  Anterior  branch  of  anterior  inter- 
costals; supplies  skin  and  anastomoses  with  superficial  branches  of  deep  epigastric  veins. 
5,  Subclavian  vein,  into  which  internal  mammary  empties.  6,  Deep  epigastric  vein.  7, 
External  iliac  vein.  8,  Circumflex  iliac  (superficial),  anastomosing  with  lumbar  and 
lower  intercostals.  9,  Internal  saphenous.  10,  Veins  around  umbilicus,  carrying  blood 
from  ligamentum  teres,  that  is,  a  vein  running  in  it,  and  anastomosing  with  the  superior 
epigastric  and  lower  intercostals. 


167 


Fig.  51. — Principal  veins  on  posterior  aspect  of  trunk  and  limb.  I,  Thoracic  duct, 
emptying  into  2,  the  left  subclavian  vein,  at  its  junction  with  the  internal  jugular.  3, 
Right  subclavian  vein.  4,  Superior  vena  cava.  5,  Left  or  hemiazygos  vein.  6,  Right 
azygos  vein,  emptying  into  4,  vena  cava  superior.  7,  Vein  draining  the  left  upper  inter- 
costal spaces,  emptying  into  the  left  innominate  vein.  8,  Popliteal  vein,  dividing  into  the 
anterior  (10)  and  posterior  (n)  veins.  9,  Short  or  external  saphenous  vein,  emptying 
into  the  popliteal  vein.  12,  Lumbar  veins.  This  illustration  also  shows  the  carrying  angle 
of  the  arms. 

II  169 


Fig.  52. — Principal  superficial  and  deep  lymphatics  on  anterior  surface  of  extremities 
and  trunk,  i,  Supraclavicular.  2,  Axillary.  3,  Cubital,  4,  Bronchial.  5,  Anterior 
mediastinal.  On  the  right  side  these  are  seen  below  the  bronchial,  communicating  with 
7,  those  of  the  liver  (see  Fig.  54).  6,  Anterior  intercostal.  8,  Plexus  of  lymphatics  around 
celiac  axis,  receiving  the  lymph  from  the  principal  solid  abdominal  viscera.  9,  Lumbar 
lymphatics,  which  receive  the  lymph  from  10,  the  deep  iliac  lymphatics,  and  also  those 
from  the  pelvis,  n,  Superficial  inguinal  lymphatics,  which  receive  the  lymph  from  the 
lower  half  of  the  back  and  abdomen,  and  from  the  external  genitals,  and  lower  portion  of 
the  rectum  and  vagina.  12,  Inguinal  lymphatics  over  saphenous  opening,  which  receive 
the  lymph  from  the  lower  extremity,  and  occasionally  from  the  external  genitalia.  In  this 
figure  the  superficial  lymphatics  are  shown  as  a  hollow  circle;  the  deep  ones  as  a  solid  one. 
13,  Location  of  swelling  in  effusion  into  shoulder-joint.  14,  Same  of  knee-joint. 

171 


Fig-  53- — Posterior  view  of  lymphatics  of  trunk  and  extremities,  also  tendon-sheaths, 
bursa?,  and  joint-effusion  areas  on  back  of  arm  and  leg.  i,  Subscapular  lymphatics.  2, 
Posterior  mediastinal  lymphatics,  projected  on  surface  of  body.  3,  Posterior  intercostal 
lymphatics.  4,  Popliteal  lymphatics.  5,  Gluteal  fold.  6,  Position  of  trochanteric  bursa. 
7,  Position  of  bursa  on  gastrocnemius  muscle  (inner  head).  8,  Metacarpophalangeal 
bursae.  9,  Common  tendon-sheath  of  the  extensors  of  the  middle,  ring,  and  little  fingers. 
10  and  n,  Extensor  tendon-sheaths  of  the  thumb,  which  are  frequently  affected  in  tendo- 
vaginitis  crepitans.  12,  Location  of  swelling  in  elbow-joint  effusion.  13,  Subdeltoid 
bursa.  14,  Location  of  sacro-iliac  joint  (right). 

173 


SURFACE    MARKINGS    OF    THE    THORACIC    ORGANS.  175 

surface  of  the  rib,  causing  the  patient  to  have  great  pain  on  inspiration 
at  the  point  of  fracture.  The  pleura  may  be  penetrated,  causing  the 
appearance  of  a  subcutaneous  emphysema.  The  lung  may  even  be 
perforated,  giving  rise  to  severe  hemorrhage.  The  ribs  should  be  ex- 
amined by  the  hands  placed  in  front  and  behind. 

Resection  of  a  rib  is  performed  either  (a) 'on  account  of  necrosis, 
tumors,  or  tuberculosis,  or  (b)  to  open  the  thoracic  cavity  for  the  relief 
of  an  empyema,  or  to  drain  a  pulmonary  abscess  or  a  pericardial  exu- 
date.  An  incision  is  made  parallel  to  a  rib  (to  drain  for  empyema, 
the  sixth  in  the  axillary  line  is  selected  on  account  of  attachment  of 
diaphragm  to  the  ninth  here)  (Figs.  43  and  44).  In  children  the 
seventh  rib  in  the  posterior  axillary  line  is  chosen  on  the  right  side, 
and  the  eighth  rib  on  the  left  side.  The  periosteum  is  incised 
and  pushed  back  in  order  not  to  wound  the  intercostal  vessels  and 
nerve  lying  in  a  groove  on  the  lower  border  of  the  rib.  The  peri- 
osteotome  is  pushed  under  the  rib,  holding  it  away  from  the  underlying 
periosteum,  the  bone  divided  with  a  bone-cutting  forceps,  and  the 
pleura  incised.  In  case  of  disease  of  the  rib,  the  periosteum  must  also 
be  removed,  as  well  as  the  soft  parts,  muscles,  etc.,  around  it.  After 
resection  of  a  rib  the  remaining  periosteum  replaces  the  gap  with  new 
bone  unless  too  much  has  been  removed. 

Thoracentesis  is  performed  for  a  pleuritic  effusion  by  the  apparatus 
of  Dieulafoy.  The  pleural  cavity  is  punctured  either  in  the  fifth  space, 
in  the  axillary,  or  the  seventh  or  eighth,  in  the  scapular,  line. 

The  lung  has  been  incised  (pneumotomy)  for  tumors,  abscesses, 
gangrene,  and  rarely  for  the  drainage  of  tubercular  cavities. 

The  pericardial  cavity  is  best  punctured,  to  draw  off  a  serous  or 
bloody  exudate,  one  inch  from  the  left  border  of  the  sternum,  in  the 
fourth  or  fifth  interspace.  To  open  it  to  suture  wounds  of  the  heart 
(Kehr),  or  to  drain  a  pyopericardium,  the  fifth  costal  cartilage  must  be 
resected  and  the  pleura  pushed  to  the  left  (Figs.  41  and  48). 

The  sternum  and  ribs  are  frequently  the  seat  of  both  tuberculosis 
and  syphilis.  An  abscess  usually  forms,  which  burrows  either  toward 
the  pleura,  forming  a  peripleuritic  abscess,  or,  if  it  affects  the  sternum 
or  costal  cartilages,  often  toward  and  into  the  anterior  mediastinum. 
An  acute  osteomyelitis  of  either  ribs  or  sternum  is  rare. 

Both  simple  and  malignant  tumors  occur,  the  most  frequent  of  the 
former  being  chondromata  and  osteomata,  and  of  the  latter  sarcomata. 
Sarcoma  is  usually  primary,  most  frequently  chondrosarcoma,  while  carci- 
noma is  secondary  to  similar  tumors  in  the  breast.  Aneurisms  from  within 
may  cause  an  erosion  of  the  ribs  or  sternum,  over  a  considerable  area. 


176  THE    THORAX. 

The  Breasts. 

In  the  female  the  mammary  gland  extends  from  the  third  to  the 
seventh  ribs  (Fig.  54).  In  the  male  it  is,  as  a  rule,  only  primitive, 
being  represented  principally  by  the  nipple,  located  in  the  fourth  inter- 
space. In  both  male  and  female  infants,  shortly  after  birth,  the  gland 
is  frequently  quite  well  developed,  decreasing  rapidly  after  a  few  weeks. 
There  are  usually  only  two  breasts,  but  cases  have  been  reported  of 
supernumerary  ones  located  in  the  axilla  or  below  the  normal  one. 
The  gland  is  inclosed  in  a  fascia  derived  from  the  superficial  pectoral 
fascia  (see  Fig.  47),  and  is  separated  from  the  deep  fascia  and  pectoralis 
major  by  considerable  loose  connective  tissue.  This  is  called  the  sub- 
mammary  space.  The  skin  covering  it  is  thin  and  freely  movable,  so 
that  the  subcutaneous  veins  are  visible.  The  nipple  is  erectile,  and 
contains  a  rich  lymphatic  plexus,  leading  directly  into  the  parenchyma. 
The  epithelium  covering  it  is  thin  and  readily  breaks,  forming  a  crack 
or  fissure.  Into  the  nipple  pass  a  number  of  fine  milk-ducts,  opening 
at  its  apex  (Fig.  48).  Up  to  the  age  of  puberty,  in  both  sexes,  the 
gland  is  composed  chiefly  of  ducts  radiating  from  the  nipple.  After 
this  period  acini  develop  from  these  ducts  in  females,  between  which 
lies  considerable  fat,  separating  the  lobules  of  parenchyma.  The  nerves 
for  the  skin  are  derived  from  the  supraclavicular  branches  of  the  cervical 
plexus ;  those  for  the  gland  from  the  intercostals  (Fig.  48).  The  arteries 
are  derived  principally  from  the  axillary  and  internal  mammary  (see 
Fig.  54).  The  most  important  is  the  long  thoracic,  which  supplies  the 
outer  lobes,  and  the  acromiothoracic,  the  upper  lobes.  The  lymph- 
atics can  be  divided  into  two  sets:  (i)  The  superficial,  which  arise 
near  the  surface  and  empty  into  the  axilla,  and  (2)  the  deeper,  which 
arise  from  the  deeper  portions,  and  pass  through  the  ribs  into  the 
anterior  mediastinum.  The  greater  number  belong  to  the  superficial 
and  empty  either  into  a  set  of  glands  along  the  lower  border  of  the 
pectoralis  major  (at  times  first  affected),  or  into  the  axillary  and  supra- 
clavicular  glands  (Fig.  54).  The  deep  lymphatics  empty  into  a  set 
along  the  internal  mammary  artery.  This  explains  why  infection  can 
travel  through  to  the  thorax,  or  even  to  the  liver  (where  metastases 
after  carcinoma  of  the  breast  often  appear  quite  early).  In  fissures 
or  cracks  of  the  nipple  infection  travels  early  along  the  lymphatics  to 
the  parenchyma,  causing  an  inflammation  of  the  gland  (mastitis),  re- 
sulting in  breaking-down  of  the  same,  and  the  formation  of  an  abscess. 
Such  a  focus  can  be  either  (a)  subcutaneous;  (b)  in  gland  proper;  (c) 
submammary  (in  loose  connective  tissue  between  it  and  the  pectoralis 
muscle).  On  account  of  the  radial  arrangement  of  the  milk-ducts, 


Fig.  54. — Lymphatic  and  blood-supply  of  female  breast.  The  breasts  are  shown 
divided  into  quadrants,  i,  Internal  mammary  arteries.  2,  Axillary  artery.  3,  Acromio- 
thoracic  artery.  4,  Long  thoracic  artery.  5,  Branches  of  internal  mammary.  6,  Lymph- 
atics radiating  parallel  to  milk-ducts  from  nipple.  7,  Lymphatic  communication 
between  breast  and  S.C.,  supraclavicular  glands.  8,  Lymphatic  channels  from  breast  to 
internal  mammary  glands.  P,  Pectoral  glands.  9,  Lymphatics  passing  from  breast  to 
pectoral  and  axillary  glands  (Ax.).  L,  Lymphatics  of  liver,  showing  connection  with 


177 


Fig-  55- — Cross-section  of  lower  portion  of  thorax  and  uppermost  portion  of  abdomen, 
at  level  of  tenth  dorsal  vertebra.  RL,  Right  lobe  of  liver.  LL,  Left  lobe  of  liver.  H, 
Hepatic  vein.  V,  Vena  cava  inferior,  lying  within  liver  substance.  A,  Aorta.  T, 
Thoracic  duct.  G,  Esophagus.  S,  Spleen.  D,  Costophrenic  sinus,  showing  the  arching 
character  of  the  diaphragm,  whose  cut  edge  lies  to  the  inner  side  of  the  letter  D.  P, 
Lower  end  of  pericardial  cavity.  LT,  Ligamentum  teres  or  suspensory  ligament  of  liver. 


179 


THE    PERICARDIUM.  l8l 

incisions  for  abscess  of  the  gland  should  radiate  from  the  nipple.  The 
various  forms  of  benign  growths  which  occur  here  are  chiefly  fibroma  and 
adenoma ;  of  malignant  growths,  carcinoma  (most  frequent)  and  sar- 
coma. The  former,  on  account  of  the  rich  lymphatic  supply,  gives  rise 
to  metastases  early.  The  modern  operation  of  Halsted  aims  to  remove 
the  gland  and  integument  in  sufficient  amount  to  include  the  superficial 
lymphatics,  the  pectoralis  major,  pectoralis  minor,  remove  all  glands  and 
fat  in  the  axilla,  and,  in  doubtful  cases,  the  glands  of  the  posterior  cer- 
vical triangle.  The  operation,  as  ordinarily  performed,  consists  in  mak- 
ing an  elliptical  incision  well  away  from  the  nipple,  prolonged  to  the  axilla. 
The  mammary  gland,  deep  pectoral  fascia,  and  entire  axillary  fat  and 
glands  are  removed.  The  breast  may  also  be  the  seat  of  a  tuberculosis. 

The  Diaphragm. 

The  diaphragm  separates  the  abdominal  from  the  thoracic  cavity, 
its  convexity  being  upward  (see  Figs.  39,  41,  42,  43,  and  44).  It  con- 
sists of  a  peripheral  (muscular),  and  a  central  tendinous  portion,  the 
former  being  attached  to  the  inner  aspects  of  the  xiphoid  and  lower 
ribs,  and  the  anterior  surfaces  of  the  upper  two  lumbar  vertebrae.  Its 
upper  surface  is  covered  by  the  diaphragmatic  pleura  on  each  side, 
and  the  pericardium  in  the  middle,  and  is  in  contact  with  the  heart 
and  lungs  (see  Figs.  41  and  55).  Its  lower  surface  is  covered  by  peri- 
toneum, and  is  in  contact  with  the  liver,  spleen,  stomach,  and  kidneys 
(see  Figs.  40,  56,  and  57).  Just  in  front  of  the  spinal  column  it  has 
an  opening  for  the  aorta  (accompanied  by  the  vena  azygos  and  thoracic 
duct).  In  front  and  to  the  left  of  the  aortic  opening  is  one  for  the  esopha- 
gus and  vagi  (see  Fig.  57).  Still  higher  and  nearer  the  center  is  an 
opening  for  the  vena  cava.  The  diaphragm  is  supplied  by  the  phrenic 
nerve,  and  by  the  internal  mammary  artery  on  its  upper  surface  and 
phrenic  artery  on  its  lower  surface. 

The  Pericardium. 

The  pericardium  (see  Figs.  41,  47,  and  58)  is  a  closed  sac,  in  which  the 
heart  and  large  blood-vessels  have  been  placed.  The  visceral  layer  is 
thin,  covers  the  heart  and  extends  up  about  2  cm.  along  the  proximal  ends 
of  the  aorta  and  other  large  vessels  arising  from  the  heart  (Figs.  37). 
The  parietal  layer  is  much  firmer.  It  is  attached  to  the  sternum  in 
front  and  the  fifth  costal  cartilage  where  the  two  layers  of  mediastinal 
pleura  recede.  Below  it  is  attached  to  the  central  tendinous  portion 
of  the  diaphragm,  and  laterally  to  the  mediastinal  pleurae.  The  cavity 
between  the  two  layers  contains  a  small  amount  of  serum  normally. 


l82  THE    THORAX. 

Behind,  the  pericardium  is  in  contact  with  the  esophagus  and  vessels 
of  the  posterior  mediastinum  (Fig.  47).  This  cavity  is  the  seat  of 
effusions  which  tend  to  displace  the  heart  toward  the  median  line. 
Paracentesis  is  performed  through  the  fifth  or  sixth  space  i  inch  to  the 
left  of  the  sternum,  and  the  fifth  costal  cartilage  is  resected  to  drain 
a  pericardial  exudate  (pericardotomy).  The  parietal  pleura  almost 
covers  the  pericardium  (see  Fig.  56),  and  must  be  pushed  to  the  left. 

The  Heart. 

The  heart  (for  surface  markings,  see  above)  is  cone-shaped,  with 
base  upward  (see  Figs.  32,  45,  and  58).  It  is  divided  by  a  vertical 
septum  into  two  lateral  halves.  This  is  indicated  in  front  and  behind 
by  a  groove,  in  which  the  coronary  vessels  run.  Each  half  is  again 
divided  by  a  horizontal  septum  into  an  upper  or  auricular  and  a  lower  or 
ventricular  portion.  The  right  half  is  the  venous,  the  left  the  arterial,  por- 
tion. The  large  systemic  veins  empty  into  the  right  upper  division  (right 
auricle).  Into  the  left  auricle  empty  the  pulmonary  veins  (four).  The 
septum  between  the  two  auricles  shows  a  depression  corresponding  to  an 
opening  (foramen  ovale)  existing  during  fetal  life  and  often  several  months 
after  birth,  permitting  free  communication  between  the  two  auricles. 

The  ventricles  and  auricles  communicate  by  an  orifice  provided  with 
three  valves  on  the  right  (tricuspid),  with  two  on  the  left,  side  (mitral). 
Opening  from  the  right  ventricle,  which  lies  in  contact  with  the  sternum,  is 
the  pulmonary  artery;  from  the  left  ventricle  (situated  immediately  be- 
hind the  pulmonary  orifice)  the  aorta  begins.  The  heart  itself  is  supplied 
by  the  coronary  arteries,  which  begin  behind  the  semilunar  valves  of 
the  aorta;  the  nerves  are  derived  from  the  vagi  and  sympathetic.  The 
former  depresses  or  slows  the  heart,  the  latter  stimulates  or  accelerates 
it.  The  heart  lies  in  the  anterior  mediastinum  (separated  from  the 
sternum  by  the  anterior  borders  of  the  lungs) ,  between  the  sternum  and 
vertebral  column.  Its  long  axis  is  directed  from  the  right  above  to  the 
left  down  and  forward  (Figs.  32  and  45).  A  left-sided  pleural  effusion 
displaces  the  heart  to  the  right.  Wounds  of  the  heart  most  frequently 
involve  the  right  ventricle.  A  number  of  successful  cases  of  suture  of 
the  heart  have  been  reported.  In  order  to  expose  it,  the  fourth  and 
fifth  left  costal  cartilages  must  be  resected,  and,  if  necessary,  a  portion 
of  the  sternum  adjacent.  In  children  the  heart  is  relatively  larger  than 
in  adults  (Figs.  32  and  58)  and  the  apex-beat  is  higher. 

The  Esophagus. 

The  esophagus  (see  Fig.  57)  begins  at  the  cricoid  cartilage  as  the 
continuation  of  the  pharynx,  passes  behind  the  trachea  in  the  neck 


Fig-  56. — Surface  markings  of  thoracic  and  abdominal  viscera.  P,  Pleura.  L,  Lung. 
MC,  Midclavicular  line.  D,  Upper  level  of  diaphragm.  RL,  Right  lobe  of  liver,  LL, 
Left  lobe  of  liver.  LC,  Lesser  curvature  of  stomach.  GC,  Greater  curvature  of  stomach. 
Y,  Pylorus.  G,  Gall-bladder.  SF,  Splenic  flexure  of  colon.  HF,  Hepatic  flexure  of  colon. 
D,  Ascending  portion  of  duodenum.  The  horizontal  and  vertical  portions  of  the  duo- 
denum can  be  followed  from  Y  to  D.  The  vertical  portion  is  under  the  letter  G.  AC, 
Ascending  colon.  C,  Cecum.  A,  Appendix.  B,  Pelvic  brim,  projected  on  anterior 
surface  of  abdomen.  X,  McBurney's  line,  from  anterior  superior  spine  of  ilium  to  um- 
bilicus. T,  Transverse  colon.  DC,  Descending  colon.  PC,  Pelvic  colon  or  sigmoid 
flexure.  R,  Rectum.  IS,  Fissure  between  upper  and  middle  lobes  of  right  lung.  IF, 
Fissure  between  middle  and  lower  lobes  of  right  lung.  H,  Portion  of  pericardium  which 
is  not  covered  by  pleura  (P).  The  figures  7,  8,  9,  and  10  are  placed  opposite  the  costal 
cartilages  of  the  respective  ribs. 


183 


Fig-  57- — Relations  of  trachea, -esophagus,  vagus,  and  aorta;  also  surface  markings 
of  chief  abdominal  viscera,  seen  from  behind,  i,  Pharnyx.  2,  Esophagus.  Note  how 
it  passes  toward  the  left  in  the  thorax  before  penetrating  the  diaphragm.  3,  Left  recurrent 
laryngeal  nerve,  arising  from  the  vagus  beneath  the  arch  of  aorta.  4,  Right  recurrent 
laryngeal,  arising  from  vagus  and  arching  around  right  subclavian  to  reach  space  between 
esophagus  and  trachea.  5,  Bifurcation  of  trachea.  Note  shorter  right,  and  longer  left 
main  bronchus.  6,  Placed  to  the  right  of  the  ascending  portion  of  arch  of  aorta,  which 
can  be  followed  to  the  left  after  giving  off  its  upper  branches  to  the  neck  and  upper  ex- 
tremity. It  is  interrupted1  in  its  course  to  show  how  it  arches  over  the  left  bronchus  and 
continues  as  the  thoracic  aorta.  7,  Liver.  8,  Cardiac  portion  of  stomach.  9,  Pyloric 
portion.  10,  End  of  ascending  portion  of  duodenum,  just  before  passing  into  jejunum. 
Between  9  and  10  the  duodenum  can  be  followed  in  its  relation  to  the  kidney,  n,  Head 
of  pancreas.  12,  Spleen.  13,  Ascending  colon.  14,  Descending  colon.  Just  above  the 
last  two  numbers  are  seen  the  splenic  and  hepatic  flexures  respectively.  15,  Left  kidney. 
1 6,  Right  kidney.  17,  Favorite  point  for  lumbar  puncture  (see  text).  18,  Termination 
of  dural  sac  at  second  sacral  vertebra.  19,  Posterior  superior  spine  of  ilium.  LV,  Left 
vagus  nerve.  RV,  Right  vagus  nerve. 

12  18; 


THE    ESOPHAGUS.  187 

to  the  left  of  the  median  line  (Fig.  42),  then  in  front  of  the  dorsal 
vertebra,  through  the  esophageal  orifice  of  the  diaphragm  to  the  stomach 
(cardiac  end)  (Figs.  30,  35,  46,  47,  and  57).  It  is  23  cm.  to  26  cm. 
(9  to  10  inches)  long;  in  children,  17  cm.  The  esophagus  is  normally 
narrower  in  some  portions  than  in  others.  The  three  narrowest  por- 
tions are  the  most  frequent  seats  of  stricture.  They  are : 

1.  Just  at  the  cricoid  cartilage. 

2.  Seven  centimeters  below  this. 

3.  Just  before  entrance  into  the  stomach. 

It  is  divided  into  a  cervical,  a  thoracic,  and  an  abdominal  portion. 
Its  cervical  relations  were  given  above  (see  Neck).  In  the  thoracic 
portion  it  lies  behind  the  aorta,  and  is  liable  to  be  compressed  by 
aneurism  of  the  same;  hence  the  passage  of  sounds  in  this  condition  is 
quite  dangerous  for  fear  of  perforating  the  vessel.  It  next  lies  behind 
the  left  bronchus  (Fig.  57).  Careless  passage  of  sounds  in  carcinoma 
may  cause  a  communication  between  the  bronchus  and  esophagus  to  be 
made.  To  the  right  lies  the  great  vena  azygos.  Foreign  bodies  may 
penetrate  the  latter  also. 

The  veins  (Fig.  79),  especially  at  the  lower  end,  may  be  enormously 
dilated,  and  varicose  in  case  of  obstruction  to  the  portal  circulation 
owing  to  nature's  attempt  to  create  a  collateral  circulation  between  the 
veins  of  the  stomach  and  those  of  the  esophagus  (emptying  into  azygos 
and  pericardiac  veins),  giving  rise,  if  a  rupture  occurs,  to  severe  hemor- 
rhage (hematemesis). 

The  pulmonary  artery  (Fig.  45)  arises  on  the  anterior  surface  of 
the  heart,  from  the  right  ventricle,  lies  just  in  front  of  the  aorta,  and 
passes  upward  to  divide  into  its  right  and  left  branches.  It  is  con- 
nected with  the  aorta  by  a  ligament  which  represents  the  obliterated 
ductus  Botalli  of  fetal  life. 

The  arch  of  the  aorta  consists  of  three  portions,  the  ascending,  the 
transverse,  and  the  descending.  The  ascending  lies  behind  the  pulmonary 
artery  at  the  level  of  the  third  costal  cartilage,  being  separated  from  the 
sternum  by  the  pericardium  only,  which  covers  it  for  about  5  cm.  (2 
inches)  (Figs.  37,  45,  and  46).  If  an  aneurism  exists  in  the  ascending 
portion,  it  may  rupture  into  the  pericardial  cavity.  The  transverse  por- 
tion of  the  arch  passes  from  a  point  corresponding  to  the  first  right  in- 
terspace directly  backward  in  the  mediastinum  to  the  left  side  of  the 
vertebral  column  (Fig.  46),  giving  off  three  branches  (innominate,  left 
common  carotid,  and  subclavian  arteries).  The  descending  or  thoracic 
aorta  begins  at  the  third  dorsal  vertebra  and  passes  along  the  median 
line  to  the  aortic  opening  in  the  diaphragm  (Fig.  57).  The  arch  of  the 


1 88  THE    THORAX. 

aorta  is  the  most  frequent  seat  of  an  aneurism.  It  may  grow  forward 
to  the  sternum,  absorbing  the  latter  and  appearing  as  a  pulsating  tumor 
just  at  the  manubrium  or  to  the  left  of  it.  The  arch  is  in  close  contact 
behind  with  the  trachea,  esophagus,  thoracic  duct,  and  left  recurrent 
nerve,  which  latter  winds  around  it  (Fig.  57).  All  of  these  may  be  com- 
pressed by  an  aneurism  or  it  can  burst  into  the  trachea  or  esophagus, 
causing  fatal  hemorrhage.  The  orifice  of  one  of  the  large  branches  of 
the  arch  of  the  aorta  may  be  closed  by  atheroma,  causing  a  disappear- 
ance of  the  pulse  in  the  corresponding  peripheral  vessel,  c.  g.,  radial 
artery. 

Vena  Cava  Superior. 

The  vena  cava  superior  (Fig.  45)  begins  opposite  the  second  and 
third  right  costal  cartilages,  lying  behind  and  to  the  right  of  the  aorta. 
Before  entering  the  pericardium,  it  receives  the  vena  azygos  (Fig.  51). 
This  latter  vessel  lies  to  the  right  of  the  spinal  column  in  the  posterior 
mediastinum.  On  the  left  side  there  is  a  similar  but  smaller  vein  (hemi- 
azygos  vein).  They  communicate  with  the  lumbar  veins  (branches  of 
the  vena  cava  inferior),  and  in  cases  of  obstruction  of  the  latter  (tumors 
of  the  abdomen)  provide  for  a  collateral  circulation  between  the  inferior 
and  the  superior  venae  cavas. 

Vena  Cava  Inferior  (see  Fig.  45). 

Passes  from  its  opening  in  the  diaphragm  to  the  right  auricle. 
Two-thirds  of  its  length  lies  inside  of  the  pericardial  cavity. 

Thoracic  Duct  (Fig.  51). 

The  thoracic  duct  begins  in  the  abdominal  cavity,  opposite  the 
second  lumbar  vertebra.  It  passes  through  the  diaphragm  with  the 
aorta,  then  upward  through  the  thorax  between  the  azygos  vein  on  the 
right,  the  aorta  on  the  left,  and  the  esophagus  in  front  (Figs.  46  and  47). 
At  the  level  of  the  fifth  dorsal  vertebra  it  crosses  to  the  left  of  the  me- 
dian line  and  ascends  to  empty  into  the  left  subclavian  vein  close  to 
its  junction  with  the  internal  jugular.  Its  relations  in  the  neck  have 
been  described  above.  Its  highest  point  is  the  left  transverse  process 
of  the  sixth  cervical  vertebra,  lying  in  front  of  the  vertebral  artery  here. 

Phrenic  Nerves  (Figs.  35,  37,  and  47). 

These  are  the  chief  motor  nerves  of  the  diaphragm.  In  the  neck 
they  lie  in  front  of  the  scalenus  anticus  on  each  side,  and  pass  down 
in  front  of  the  subclavian  artery  into  the  thorax.  In  the  thorax  they 
lie  between  the  pericardial  pleura  and  pericardium.  The  left  passes  to 


PLEURA.  189 

the  left  of  the  median  line  in  front  of  the  aorta  and  root  of  the  lung, 
to  make  room  for  the  heart.  The  right  is  shorter,  passes  on  the  right 
side  of  the  innominate  (right)  vein,  and  vena  cava  superior,  to  the  dia- 
phragm— lying  external  to  the  pericardium,  as  on  the  left  side. 

Thoracic  Portion  of  Vagus  (Figs.  46,  47,  and  57). 

The  right  vagus  passes  from  the  neck,  where  it  lies  in  front  of  the 
subclavian  artery,  into  the  thorax,  lying  in  the  latter  at  first  between  the 
right  innominate  and  azygos  veins  and  trachea,  then  close  to  the  esopha- 
gus, gradually  passing  behind  and  through  the  diaphragm  with  it.  The 
left  differs  from  the  right  in  lying  in  front  of  the  arch  of  the  aorta, 
giving  off  the  recurrent  laryngeal  here  (hence  compressed  here  by  aneu- 
risms). 

Pleurae. 

At  the  upper  end  of  the  thoracic  cavity  the  parietal  pleura  projects 
one  and  one-half  inches  through  the  superior  aperture  of  the  thorax, 
being  attached  firmly  to  the  vertebral  column,  forming  the  apex  of 
the  pleural  cavity.  This  portion  is  in  close  relation  with  the  subclavian 
artery  and  brachial  plexus  on  both  sides  of  the  neck,  and  with  the  tho- 
racic duct,  in  addition,  on  the  left  side  (Figs.  28,  35,  and  41).  At  the 
lower  end  of  the  pleural  cavity  (or  space  between  the  parietal  and  vis- 
ceral pleurae) ,  where  the  parietal  is  reflected  on  the  upper  surface  of  the 
diaphragmatic  pleura,  there  is  a  small  space,  the  complementary  or 
sinus  pleurae,  sometimes  called  the  costophrenic  sinus  (Fig.  55),  which 
is  empty,  except  during  deep  inspiration;  it  contains  normally  a  few 
drops  of  fluid.  In  this  sinus  pleuritic  effusions  first  collect,'  so  that  on 
the  surface  of  the  body  the  normal  markings  of  the  lower  limits  of  the 
lung  are  raised  and  the  inspiratory  descent  of  the  lower  border  of  the 
lung  is  absent.  This  sinus  is  also  obliterated  in  tumors,  etc.,  of  the 
abdomen,  which  push  the  diaphragm  upward.  The  parietal  and  visceral 
pleurae  are  in  such  intimate  contact  with  each  other  normally  that 
there  is  no  pleural  cavity.  Such  a  space  is  only  present  when  the  lung 
is  pushed  toward  the  vertebral  column  by  a  collection  of  fluid  (hydro- 
thorax  or  serothorax  or  hemothorax)  or  air  (pneumothorax),  or  after 
death  owing  to  the  collapse  of  the  lung  (Figs.  46  and  47).  On  account 
of  the  close  proximity  of  the  two  pleural  layers,  an  inflammation  of 
the  visceral  will  be  immediately  referred  to  a  corresponding  point  of  the 
parietal.  Similarly,  an  inflammation  of  that  portion  of  the  visceral 
layer  covering  the  inferior  surface  of  the  lung  is  often  referred  to  the 
abdomen,  especially  in  children  (diaphragmatic  pleurisy)  and  may  sim- 


THE     THORAX. 

ulate  an  abdominal  affection.  At  the  junction  of  the  pleura  and  dia- 
phragm the  pleura  is  reflected  over  the  surface  of  the  diaphragm,  then 
again  along  the  mediastinum  as  far  as  the  root  of  the  lung,  becoming 
here  the  mediastinal  pleura.  The  relations  of  the  pleurae  are  best  seen  in 
a  cross-section  at  the  level  of  the  eighth  dorsal  vertebra;  i.  e.,  the  fourth 
rib  in  front  (Fig.  47).  The  two  mediastinal  pleurae  meet  behind  the 
sternum,  then  separate  to  inclose  the  pericardium,  extending  as  far 
back  as  the  root  of  the  lungs.  From  the  point  of  attachment  of  the 
mediastinal  pleura  to  the  root  of  the  lung  it  is  reflected  upon  the  mesial 
surface  of  the  lungs  as  the  visceral  pleura.  The  latter  then  continues 
as  the  covering  of  the  lung  (on  both  sides),  dipping  into  the  interlobar 
fissures,  and  lining  them  with  pleura.  At  the  posterior  surface  of  the 
lung  it  dips  in  again  as  far  as  the  root  of  the  lung,  being  reflected 
upon  itself.  Its  continuation  covers  the  lateral  aspect  of  the  esophagus 
and  aorta,  forming  the  posterior  mediastinal  pleura  again.  At  the 
points  of  attachment  to  the  sternum  in  front  and  vertebrae  behind,  the 
mediastinal  pleura  is  reflected  on  either  side  upon  the  inner  aspect  of 
the  thorax  as  the  parietal  or  sternocostal  pleura.  The  latter  is  seen  to 
cover  the  interior  of  the  thorax,  being  attached  to  the  inner  surface  of 
the  ribs,  except  where  the  pericardium  is  attached. 

The  pleurae  may  at  times  extend  beyond  the  level  of  the  last  rib 
in  front  of  the  lumbar  vertebrae,  and  may  thus  be  opened  in  operations 
upon  the  kidney  (see  Abdomen).  This  is  especially  true  when  the 
twelfth  rib  is  quite  short  (Fig.  57). 

The  Trachea  (see  Fig.  45). 

The  trachea  begins  at  the  sixth  cervical  (below  cricoid  cartilage), 
and  ends  at  the  fourth  dorsal  vertebra  (Fig.  57)  (level  of  second  ribs 
or  at  junction  of  first  and  second  portions  of  sternum).  Behind  the 
sternum,  lying  in  front  of  the  trachea,  are  the  left  innominate  vein,  the 
thymus  (in  children)  (Figs.  32  and  58),  and  the  innominate  artery  (Figs. 
45  and  48).  The  left  common  carotid  lies  to  the  left  of  the  trachea.  A 
little  lower  down  the  trachea  is  crossed  by  the  arch  of  the  aorta  and 
pulmonary  artery.  Behind  it  lies  the  esophagus  (see  Fig.  46).  Aneu- 
risms of  the  arch  of  the  aorta  frequently  press  upon  the  trachea,  caus- 
ing intense  dyspnea.  The  trachea  divides  into  two  main  bronchi  behind 
the  pulmonary  artery.  At  its  point  of  bifurcation  the  trachea  is  sur- 
rounded by  a  number  of  lymph-nodes  (bronchial),  which  may  press 
upon  it  when  diseased,  or  rupture  into  it  when  they  are  the  seat  of  a 
tubercular  process.  A  primary  carcinoma  arising  from  these  nodes 
may  compress  the  trachea.  The  right  and  left  main  bronchi  take 


THE    LUNGS.  19! 

an  arched  course;  the  left  is  longer,  and  hence  the  more  frequent  lodg- 
ing-point of  foreign  bodies.  The  left  bronchus  lies  in  front  of  the  aorta, 
the  artery  arching  over  it  to  reach  the  vertebrae  (see  Figs.  45,  46,  and  57). 
Hence  it  is  often  compressed  by  aneurisms  of  the  aorta.  The  esopha- 
gus lies  behind  the  trachea  in  its  entire  course  (Figs.  30,  35,  and  46). 
The  main  bronchi  give  off  ventral  and  dorsal  branches.  They  are  sup- 
plied by  branches  of  the  aorta  (bronchial  arteries),  which  also  nourish 
the  lungs  and  anastomose  with  the  branches  of  the  pulmonary  artery, 
so  that  in  case  of  obstruction  in  the  latter  a  collateral  circulation  can 
develop. 

Lungs  (see  Figs.  41  and  47). 

The  right  is  divided  into  three,  the  left  into  two,  lobes.  Their 
relations  to  the  surface  have  been  given  above.  They  have  an  outer 
convex  surface,  lying  in  close  apposition  with  the  parietal  pleura; 
hence,  the  lung  is  often  injured  in  fractures  of  the  ribs,  etc.,  giving  rise 
to  traumatic  pneumonia.  The  inner  or  medial  surface  is  concave,  to 
inclose  the  heart. 

A  depression  in  this  surface,  known  as  the  hilum,  is  the  point  of 
entrance  of  the  pulmonary  artery  and  vein,  of  the  bronchi,  bronchial 
arteries,  veins,  and  lymph-vessels.  These  structures,  all  intimately 
bound  together  by  connective  tissue,  are  known  as  the  root  of  the 
lung.  The  lower  surface  or  base  fits  the  convexity  of  the  diaphragm 
closely  (Fig.  40).  On  the  right  side  the  base  is  formed  by  the  lower 
and  middle  lobes;  on  the  left  side  by  the  lower  lobe  only  (Fig.  41).  On 
the  right  side  the  lobes  are  separated  from  the  liver  only  by  the  dia- 
phragm. For  this  reason  right-sided  subphrenic  or  hepatic  abscess  is 
liable  to  rupture  into  the  right  lung  (see  Figs.  40,  41,  and  55).  The  apex 
of  each  lung  (relations  given  above)  projects  one  and  one-half  inches 
above  the  clavicle.  It  has  no  complementary  space,  and  is  the  least 
expansible  of  any  portion  of  the  lung.  The  lower  border  of  the  left 
upper  lobe  has  some  degree  of  respiratory  excursion  over  the  upper 
border  of  the  heart.  Use  of  this  fact  is  often  made  in  determining  the 
upper  border  of  cardiac  dulness. 

In  adults  the  lungs  are  of  a  grayish  color;  in  children,  reddish. 
In  the  former  they  are  streaked  with  black,  outlining  the  alveoli  (coal 
pigment).  The  respiratory  circulation  of  the  lungs  is  carried  on  by 
the  pulmonary  artery  and  vein,  forming  a  capillary  network  in  each 
alveolus.  The  nutrition  is  provided  for  by  the  bronchial  arteries. 
The  lymphatics  form  a  rich  network  around  each  alveolus,  and  return 
the  lymph  to  the  bronchial  glands  at  the  root  of  the  lung.  Seventy- 


1Q2  THE    THORAX. 

five  per  cent,  of  all  metastatic  abscesses  in  pyemia  occur  in  the  lungs, 
on  account  of  the  fine  capillary  network  arresting  the  emboli.  Wounds 
of  the  lungs,  unless  they  involve  a  large  vessel,  are  not  fatal,  as  a  rule.  If 
there  is  a  wound  of  the  lung,  air  often  escapes,  producing  pneumo- 
thorax;  and  if,  at  the  same  time,  there  is  a  wound  of  the  parietes, 
there  is  subcutaneous  emphysema.  Pneumonia  may  either  affect  a 
few  lobules  around  a  bronchus  (bronchopneumonia)  or  an  entire  lobe 
or  lung  (lobar  pneumonia).  When  the  lung  is  displaced  by  a  pleuritic 
effusion,  it  always  collapses  toward  the  root.  If  pressure  is  not  relieved, 
the  condition  of  collapse  may  become  permanent  (atelectasis). 

The  Mediastinum. 

The  mediastinum  is  the  space  between  the  two  layers  of  mediastinal 
pleura  (see  "Figs.  46  and  47).  It  has  an  anterior  portion  lying  in  front 
of  the  roots  of  the  lungs,  and  a  posterior  behind  them,  the  two  being 
directly  continuous.  The  anterior  contains  the  thymus  gland  above 
(Figs.  32  and  58),  which  develops  during  the  last  months  of  fetal  life, 
and  persists  as  a  bi-lobed  pale-red  structure  until  the  age  of  puberty. 
It  lies  behind  the  first  portion  of  the  sternum,  in  front  of  the  innominate 
vein  (left)  and  trachea.  In  rare  cases  it  may  compress  the  latter, 
causing  asphyxia.  Below,  the  anterior  portion  of  the  mediastinum  con- 
tains the  heart  and  beginning  of  the  large  vessels.  It  is  connected 
with  the  space  between  the  outer  and  middle  (previsceral)  layers  of 
the  deep  cervical  fascia,  and  abscesses  between  these  are  liable  to  drain 
into"  it  (from  cervical  glands,  etc.). 

The  posterior  portion  of  the  mediastinum  lies  behind  the  pericardium. 
It  contains  the  esophagus,  to  each  side  of  which  are  the  vagi,  descending 
aorta,  azygos  vein,  and  thoracic  duct  (Figs.  39  and  41).  The  posterior 
portion  of  the  mediastinum  communicates  with  the  prevertebral  space 
in  neck  (Fig.  31).  The  entire  mediastinum  is  occasionally  the  seat 
of  sarcomata,  causing  marked  pressure  symptoms  (varicose  veins  of 
skin  of  thorax)  and  dyspnea.  An  obstruction  of  the  venae  cavae  as 
the  result  of  such  a  tumor  is  relieved  (Fig.  50)  through  a  collateral 
circulation  established  through  the  intercostal  veins  with  the  azygos 
and  subclavian  (through  internal  mammary)  veins. 


Fig.  58. — Relations  of  abdominal  and  thoracic  viscera  in  a  child  of  seven  years,  i, 
Thymus  gland.  2,  Outline  of  right  pleura.  2',  Left  pleura.  3,  Lower  border  of  right 
lung.  3',  Lower  border  of  left  lung.  4,  Upper  border  of  liver.  Note  the  large  size  of  the 
liver  in  the  child.  4',  Lower  border  of  liver.  5,  Interlobar  fissure  between  right  upper 
and  right  middle  lobes.  6,  Interlobar  fissure  between  right  middle  and  right  lower  lobes. 
6',  Fissure  between  left  upper  and  left  lower  lobes.  7,  Gall-bladder.  8,  Transverse 
colon.  9,  Ascending  colon  and  cecum  (observe  the  relatively  large  size  of  cecum).  10, 
Descending  colon,  n,  Appendix.  12,  Internal  abdominal  ring.  13,  External  abdom- 
inal ring.  P,  Pericardium. 


193 


EXAMINATION    OF   THE   ABDOMEN   IN   THE   LIVING.  195 

THE  ABDOMEN. 

THE  abdomen  has,  as  its  external  limits,  the  costal  arches,  folds  of 
the  groin  (inguinal),  and  crests  of  the  ilium.  These  do  not  correspond 
to  the  internal  limits,  which  are  the  diaphragm  above  and  the  outlet 
of  the  pelvis  below.  It  has  a  bony  support  along  its  median  line  behind 
(vertebral  column)  and  along  the  upper  and  lower  portions  of  its 
lateral  walls  in  the  form  of  the  lower  ribs  and  walls  of  the  pelvis,  but 
has  no  bony  support  in  front  and  for  that  portion  of  its  sides  which 
lies  between  the  last  rib  and  the  crest  of  the  ilium.  Hence,  these  parts 
can  adapt  themselves  to  changes  in  form  readily.  This  is  especially 
true  of  the  anterior  abdominal  wall.  The  abdominal  walls  are  so 
elastic  that  a  blow — for  example,  a  kick,  or  a  fall  upon  some  blunt 
object — or  a  crushing  force  may  cause  no  injury  to  the  surface  and 
still  produce  serious  laceration  of  the  viscera,  solid  and  hollow.  Of 
292  cases  of  abdominal  contusion  collected  by  Makins,  without  any  ex- 
ternal signs,  nearly  one-third  showed  ruptures  of  the  viscera. 

The  degree  of  prominence  or  retraction  of  the  abdomen  de- 
pends normally:  (i)  upon  the  amount  of  distention  of  the  hollow  viscera; 

(2)  upon  the  size  of  the  solid  viscera,  such  as  the  liver,  spleen,  etc.;  and 

(3)  upon  the  amount  of  fat  in  the  subcutaneous  tissue  and  omentum.  In 
children  the  disproportionately  large  size  of  the  liver,  and  the  fact  that 
the  pelvis  is  quite  small  and  can  hold  but  few  of  the  intestinal  coils, 
causes  the  abdomen  to  be  especially  prominent  (see  Figs.  23  and  58). 
Under  pathologic  conditions  the  abdomen  becomes  more  prominent 
when  there  is  a  collection  of  free  or  encapsulated  fluid,  when  tumors 
are  present,  or  when  there  is  excessive  distention  of  the  intestine  (tym- 
panites) from  any  cause.     Retraction  of  the  abdomen  is  a  symptom 
of  lead  colic,  of  tubercular  meningitis,  or  of  great  emaciation. 

Examination  of  the  Abdomen  in  the  Living. — i.  Note  the  linea 
alba,  which  is  indicated  by  a  slight  median  groove  above  the  umbilicus, 
and  below  the  same  by  a  line  of  hair  or  deposit  of  brownish  pigment 
frequently  descending  from  the  umbilicus  to  the  symphysis  pubis. 

2.  In  muscular  individuals  note  the  slight  transverse  depressions  in 
the  course  of  the  recti  muscles.     These  are  the  linea  transversae  (see 
Fig.  66),  which  interrupt  the  rectus  at  various  points  in  its  course,  the 
one  opposite  the  umbilicus  being  especially  marked.     Some  individuals 
have  the  ability  to  cause  the  intervening  portions  of  muscle  to  stand 
out  prominently  and  thus  resemble  tumors. 

3.  Note  the  linea  semilunaris,  which  corresponds  to  the  point  of 


196  THE    ABDOMEN. 

junction  of  the  aponeuroses  of  the  muscles  of  the  anterior  abdominal 
wall.  It  is  represented  by  a  slightly  curved  line  from  the  tip  of  the 
ninth  costal  cartilage  to  the  pubic  spine.  Above  the  umbilicus  it  is 
represented  by  a  shallow  depression. 

4.  Examine  the  umbilicus.     This  is  readily  seen,  except  in  very 
stout  persons.    It  corresponds  behind  to  the  disc  between  the  third  and 
fourth  lumbar  vertebras.      Not  infrequently,   there  is  a  mass  of  fat 
between  the  fibrous  portion,  or  umbilical  ring,  and  the  skin. 

5.  Palpate  the  anterior  and  posterior  superior  spines  of  the  ilium, 
which  can  be  readily  felt  except  in  very  stout  people.     The  first-named 
forms  the  outer  boundary  of  Poupart's  ligament,  and  is  used  as  a  fixed 
point  in  many  measurements  of  the  lower  limb  (see  Fig.  122).     Between 
the  two  spines  on  either  side  can  be  felt  the  crest  of  the  ilium. 

6.  Palpate  Poupart's  ligament.     It  is  a  firm  band  which  can  be  felt 
extending  from  the  anterior  superior  spine  to  a  bony  prominence  upon 
the  upper  surface  of  the  symphysis  pubis,  just  external  to  the  outer 
border  of  the  rectus.     This  bony  point  is  the  pubic  spine.     (See  Figs. 
59  and  66.) 

7.  The  pubic  spine  can  be  best  felt  by  invaginating  the  scrotum  with 
the  index-finger  passed  along  the  spermatic  cord  in  the  male,  and  in 
the  female  by  adducting  the  thigh  and  thus  making  prominent  the 
tendon  of  origin  of  the  adductor  longus  muscle. 

8.  By  the  same  procedure  the  external  abdominal  ring  can  be  felt, 
both  in  the  male  and  female,  admitting  the  tip  of  the  index-finger, 
in  the  adult,  and  the  tip  of  the  little  finger  in  children,  under  normal 
conditions,  although  one  occasionally  meets  with  individuals  in  whom 
the  external  abdominal  ring  will  easily  admit  two  fingers  under  normal 
conditions. 

9.  Over  the  back  of  the  abdominal  region,  especially  when  the 
patient  stands  erect,  can  be  felt  the  masses  of  the  erector  spinae  muscles, 
and  in  the  groove  between  them,  the  spines  of  the  lumbar  vertebrae 
(see  chapter  on  Spine). 

10.  Palpate  the  ensiform  process  and  the  costal  cartilages  of  the 
ribs  which  form  the  costal  arches.  Mark  with  a  pencil  the  tips  of  the 
seventh,  eighth,  ninth,  and  tenth  costal  cartilages,  and  also  the  free 
ends  of  the  eleventh  and  twelfth  ribs,  which  can  be  palpated  in  lean 
individuals  by  inserting  the  tips  of  the  fingers  just  above  the  crests  of 
the  ilium. 

Surface  Markings. 

i.  The  abdominal  aorta  corresponds  to  a  line  drawn  from  a  point 


Fig.  59. — Surface  markings  of  kidneys,  ureters,  and  vessels  of  abdomen,  i,  Vena 
cava  inferior.  2,  Aorta.  The  celiac  axis  is  shown  just  below  the  figure  2.  3  and  4,  Right 
and  left  renal  veins.  5  and  6,  Right  and  left  renal  arteries.  7  and  8,  Right  and  left  ureters. 
Q,  Left  spermatic  vein,  arising  from  left  renal  vein.  10,  Right  spermatic  vein,  arising 
from  vena  cava  inferior,  n,  Superior  mesenteric  artery.  12  and  13,  Right  and  left 
spermatic  arteries.  14,  External  iliac  arteries.  15,  External  iliac  veins.  R.K.,  Right 
kidney.  L.K.,  Left  kidney.  S.P.,  Spleen. 


197 


DIVISIONS    OF    ABDOMEN.  199 

a  little  to  the  left  of  the  ensiform  process  to  a  second  point  three- 
fourths  of  an  inch  below  the  umbilicus  and  also  to  the  left  of  the  mid- 
dle line.  The  point  at  which  the  celiac  axis  is  given  off  from  the  aorta 
is  four  or  five  inches  above  the  umbilicus.  The  renal  arteries  are  given 
off  at  a  point  three  and  a  half  inches  above  the  umbilicus.  (See  Figs.  59 
and  70.) 

2.  The  common  and  external  iliac  arteries  correspond  to  a  line 
from  the  point  of  termination  of  the  aorta  (three-fourths,  of  an  inch 
below  and  a  little  to  the  left  of  the  umbilicus)  to  a  point  midway  between 
the  anterior  superior  spine  of  the  ilium  and  the  pubic  symphysis.     The 
upper  third  of  this  line  corresponds  to  the  common  iliac  (Fig.  53), 
the  lower  two-thirds  to  the  external  iliac. 

3.  The  deep  epigastric  artery  corresponds  to  a  line  from  the  middle 
of  Poupart's  ligament  to  the  umbilicus  (see  Fig.  69). 

4.  The  inferior  vena  cava  and  common  and  external  iliac  veins 
correspond  to  the  lines   given  above  for  the  aorta  and  the  iliac  arteries 
respectively,  but  lie  a  little  to  the  right  of  the  same  (Figs.  59  and  70). 

Divisions  of  Abdomen. 

Before  proceeding  to  give  the  surface  markings  for  the  superficial 
and  more  deeply  situated  abdominal  viscera,  it  will  be  necessary  to 
recall  that  the  abdomen  is  arbitrarily  divided  into  nine  regions,  by 
two  vertical  and  two  horizontal  lines.  The  vertical  ones  are  drawn 
on  each  side  through  Poupart's  ligament  at  a  point  midway  between 
the  anterior  superior  spine  of  the  ilium  and  the  median  line  at  the 
upper  border  of  the  symphysis  pubis.  The  two  horizontal  lines  are, 
one  drawn  through  the  two  anterior  superior  spines  of  the  ilium,  and 
another  at  the  level  of  the  lowest  part  of  the  tenth  costal  cartilages 
(Fig.  60). 

The  subdivisions  of  the  upper  zone,  from  right  to  left,  are  the  right 
hypochondriac,  the  epigastric,  and  the  left  hypochondriac  regions. 
Those  of  the  middle  zone,  from  right  to  left,  the  right  lumbar,  the 
umbilical,  and  the  left  lumbar  regions.  Of  the  lower  zone,  the  right 
iliac,  the  hypogastric,  and  the  left  iliac  regions. 

The  relations  of  the  various  organs  of  the  abdomen  to  the  surface 
are  the  following: 

The  liver  lies  in  the  right  hypochondriac  and  epigastric  regions. 
Its  upper  border,  apex  of  concavity  of  right  lobe,  extends  as  high  as  the 
right  fourth  interspace  (see  Fig.  61)  in  the  mammary  line.  This  upper 
marking  is,  however,  at  a  deep  level;  in  reality,  on  the  surface  the  upper 
border  of  the  liver  is  at  the  lower  border  of  the  sixth  rib  in  the  mammary 


200  THE    ABDOMEN. 

line,  the  lower  border  of  the  eighth  rib  in  the  mid-axillary  line,  and 
at  the  lower  border  of  the  tenth  rib  in  the  scapular  line.  Its  lower 
margin  corresponds  superficially  to  the  eighth  rib  in  the  axillary  line, 
tenth  dorsal  vertebra  behind  (see  Fig.  62),  and  in  front  to  a  line  drawn 
from  the  tip  of  the  ninth  right  costal  cartilage  to  the  eighth  left  costal 
cartilage.  At  a  deep  level  it  extends  to  the  eighth  rib  (right)  behind. 
The  left  border  of  the  left  lobe  of  the  liver  extends  as  far  as  the  left 
parasternal  line  (Fig.  61). 

5.  The  gall-bladder  is  at  the  angle  between  the  ninth  costal  carti- 
lage and  the  outer  border  of  the  right  rectus  (Figs.  61  and  63). 

6.  The  stomach  lies  in  the  epigastric  and  left  hypochondriac  regions. 
Its  upper  border  (lesser  curvature)  is  overlapped  by  the  lower  margin 
of  the  liver  (see  Fig.  61).     Its  lower  border  or  greater  curvature  crosses 
behind  the  left  costal  arch  opposite  the  tip  of  the  ninth  costal  cartilage, 
and  extends  as  far  downward  as  a  distance  of  about  two  finger-breadths 
above  the  umbilicus  (two  inches).     The  pylorus  lies,  as  a  rule,  about 
one  inch  to  the  right  of  the  middle  line.     When  the  stomach  is  empty, 
the  pylorus  generally  lies  in  the  middle  line.     When  distended,  it  may 
reach  two  or  even  three  inches  to  the  right  of  the  middle  line.     The 
pyloric  portion  of  the  stomach  is  practically  bisected  by  a  horizontal 
plane  which  passes  through  the  abdomen  midway  between  the  supra - 
sternal  notch  and  pubic  symphysis  (Addison).      The  fundus  of  the 
stomach  lies  under  the  left  dome  of  the  diaphragm  (see  Figs.  61  and 
62).     The  cardiac  orifice  corresponds  to  a  point  over  the  left  seventh 
costal  cartilage,  one  inch  from  the  sternum. 

7.  Small  Intestines. — The  duodenum  corresponds  on  the  surface 
(see  Figs.  63  and  64)  to  the  right  half  of  the  epigastric  region  behind  the 
eighth  costal  cartilage  (horizontal  portion);  the  second  or  vertical  por- 
tion lies  midway  between  the  median  line  of  the  body  and  the  vertical 
line  which  separates  the  right  hypochondriac  from  the  epigastric  regions. 
The  third  or  ascending  portion  passes  obliquely  upward  across  the  body 
from  the  right  half  of  the  umbilical  region  to  the  left  half  of  the  same, 
where  it  joins  with  the  jejunum  at  a  point  one  inch  to  the  right  of  the 
median  line  (duodeno-jejunal  flexure),  at  a  point  about  midway  between 
the  ensiform  process  and  umbilicus  (Figs.  61,  62,  63,  and  64). 

The  small  intestines  lie,  as  it  were,  within  a  frame  formed  by  the  large 
intestine  (see  Fig.  61).  They  overlap  the  ascending  and  descending 
colon  respectively  and  extend  downward  into  the  pelvis.  The  portions 
which  come  in  contact  with  the  anterior  abdominal  wall  (being  sepa- 
rated from  it  by  the  omentum)  are  to  some  extent  the  jejunum,  but 
chiefly  the  ileum. 


Fig.  60. — Surface  markings  of  pleura,  lungs,  pericardium,  and  fissures,  also  divisions 
of  abdomen.  S,  Sternal  line.  LS,  Lateral  sternal  line.  PS,  Parasternal  line.  MC, 
Midclavicular  line.  1C,  Infraclavicular  region.  MR,  Mammary  region.  M,  Trans- 
verse mammary  line.  PL,  Pleura,  crossing  midclavicular  line  at  seventh  rib.  Its  rela- 
tion on  the  left  side  to  the  pericardium  should  be  noted.  L,  Surface  outline  of  lungs 
following  closely  that  of  pleura.  It  crosses  the  sixth  rib  at  the  midclavicular  line.  P, 
Pericardium  outlined  on 'surface.  Its  relations  to  the  pleura  should  be  followed.  D, 
Diaphragm.  The  interlobar  fissures  are  seen  upon  the  right  and  left  sides,  showing  that 
upon  the  right  side  the  right  upper,  middle,  and  lower  lobes  come  to  the  surface  of  the 
chest;  upon  the  left  side  the  left  upper  and  lower.  RH,  Right  hypochondriac  region. 
EP,  Epigastric  region.  LH,  Left  hypochondriac  region.  RL,  Right  lumbar  region. 
UM,  Umbilical  region.  LL,  Left  lumbar  region.  RI,  Right  iliac  region.  HY,  Hypo- 
gastric  region.  LI,  Left  iliac  region.  The  dots  between  RL  and  RI  indicate  spines  of 
ilium. 

J3  201 


Fig.  61. — Surface  markings  of  thoracic  and  abdominal  viscera.  P,  Pleura.  L,  Lung. 
MC,  Midclavicular  line.  D,  Upper  level  of  diaphragm.  RL,  Right  lobe  of  liver,  LL, 
Left  lobe  of  liver.  LC,  Lesser  curvature  of  stomach.  GC,  Greater  curvature  of  stomach. 
Y,  Pylorus.  G,  Gall-bladder.  SF,  Splenic  flexure  of  colon.  HF,  Hepatic  flexure  of  colon. 
D,  Ascending  portion  of  duodenum.  The  horizontal  and  vertical  portions  of  the  duo- 
denum can  be  followed  from  Y  to  D.  The  vertical  portion  is  under  the  letter  G.  AC, 
Ascending  colon.  C,  Cecum.  A,  Appendix.  B,  Pelvic  brim,  projected  on  anterior 
surface  of  abdomen.  X,  McBurney's  line,  from  anterior  superior  spine  of  ilium  to  um- 
bilicus. T,  Transverse  colon.  DC,  Descending  colon.  PC,  Pelvic  colon  or  sigmoid 
flexure.  R,  Rectum.  IS,  Fissure  between  upper  and  middle  lobes  of  right  lung.  IF, 
Fissure  between  middle  and  lower  lobes  of  right  lung.  H,  Portion  of  pericardium  which 
is  not  covered  by  pleura  (P).  The  figures  7,  8,  9,  and  10  are  placed  opposite  the  costal 
cartilages  of  the  respective  ribs. 


203 


Fig.  62. — Relations  of  trachea,  esophagus,  vagus,  and  aorta;  also  surface  markings 
of  chief  abdominal  viscera,  seen  from  behind,  i,  Pharnyx.  2,  Esophagus.  Note  how 
it  passes  toward  the  left  in  the  thorax  before  penetrating  the  diaphragm.  3,  Left  recurrent 
laryngeal  nerve,  arising  from  the  vagus  beneath  the  arch  of  aorta.  4,  Right  recurrent 
laryngeal,  arising  from  vagus  and  arching  around  right  subclavian  to  reach  space  between 
esophagus  and  trachea.  5,  Bifurcation  of  trachea.  Note  shorter  right,  and  longer  left 
main  bronchus.  6,  Placed  to  the  right  of  the  ascending  portion  of  arch  of  aorta,  which 
can  be  followed  to  the  left  after  giving  off  its  upper  branches  to  the  neck  and  upper  ex- 
tremity. It  is  interrupted  in  its  course  to  show  how  it  arches  over  the  left  bronchus  and 
continues  as  the  thoracic  aorta.  7,  Liver.  8,  Cardiac  portion  of  stomach.  9,  Pyloric 
portion.  10,  End  of  ascending  portion  of  duodenum,  just  before  passing  into  jejunum. 
Between  9  and  10  the  duodenum  can  be  followed  in  its  relation  to  the  kidney,  n,  Head 
of  pancreas.  12,  Spleen.  13,  Ascending  colon.  14,  Descending  colon.  Just  above  the 
last  two  numbers  are  seen  the  splenic  and  hepatic  flexures  respectively.  15,  Left  kidney. 
1 6,  Right  kidney.  17,  Favorite  point  for  lumbar  puncture  (see  text).  18,  Termination 
of  dural  sac  at  second  sacral  vertebra.  19,  Posterior  superior  spine  of  ilium.  LV,  Left 
vagus  nerve.  RV,  Right  vagus  nerve. 

205 


SURFACE   MARKINGS   OF   ABDOMINAL   VISCERA.  207 

8.  Large  Intestine.— The  surface  markings  of  the  cecum  corre- 
spond to  the  right  iliac  and   hypogastric  regions,  just   below  a   line 
drawn  from  the  anterior  superior  spine  to  the  umbilicus,  the  ileocecal 
valve  being  situated  at  a  point  one  inch  below  the  mid-point  of  this  line. 
The  appendix  lies  in  the  right  iliac  and  hypogastric  regions,  in  its  typical 
position  hanging  down  over  the  brim  of  the  pelvis  (see  Fig.  61).     Its  base 
or  orifice  corresponds  approximately  to  a  point  two  inches  below  the 
mid-point  of  the  line  drawn  from  the  anterior  superior  iliac  spine  to  the 
umbilicus.     The  most  frequent  point  (McBurney's)  at  which  pain  is 
felt  in  the  appendiceal  inflammations  is  midway  in  this  line,  which  does 
not  correspond   exactly  anatomically  to  the  position  of  the  appendix. 
The  ascending  colon  extends  vertically  upward  in  the  right  lumbar  and 
right  hypochondriac  regions,  as  high  as  the  tenth  costal  cartilage  (he- 
patic flexure),  lying  immediately  to  the  right  of  the  gall-bladder.     The 
transverse  colon  crosses  the  upper  part  of  the  umbilical  region,  ascending 
obliquely  from  the  left  lumbar  to  the  left  hypochondriac  region  (see  Figs. 
43,  44,  61,  and  62)  as  far  as  the  lower  extremity  of  the  spleen  (splenic 
flexure).     The  descending  colon  passes  vertically  downward  in  the  left 
lumbar  and  iliac  regions,  passing  over  into  the  iliac  colon  (sigmoid  flex- 
ure) in  the  hypogastric  region  (see  Fig.  61). 

9.  The  Pancreas.— This  lies  immediately  below  the  stomach  at  a 
deep  level,  occupying  the  curve  of  the  duodenum  at  the  lowest  portion  of 
the  epigastric  region  (head  of   pancreas)  and  crossing  this  region  ob- 
liquely upward  to  the  left,  as  far  as  the  left  hypochondriac  region  (the 
tail)  (Figs.  61,  62,  63,  and  64). 

10.  The  spleen  extends  as  far  forward  as  the  costo-clavicular  line 
(line  from  inner  end  of  clavicle  to  tip  of  tenth  costal  cartilage),  occa- 
sionally to  the  mid-axillary  line  (see  Figs.  43,  62,  and  64),  and  from  the 
ninth  to  the  eleventh  ribs. 

1 1 .  The  surface  markings  of  the  kidneys  on  the  anterior  surface  of 
the  abdomen  are  as  follows:     The  upper  borders  extend  as  high  in 
the  epigastric   region    as  a    line  drawn  about    two   inches  below  the 
ensiform  or  xiphoid  process.     The  right  always  lies  lower  than  the  left. 
The  lowest  point  of  the  kidney  reaches  down  to  a  line  drawn  between  the 
lower  borders  of  the  curves  of  the  tenth  costal  cartilages  (Figs.  59  and 
64).     Posteriorly,  the  kidneys  extend  on  the  surface  of  the  body  from 
the  eleventh  rib  to  the  level  of  the  third  lumbar  spine,  the  left  kidney 
lying  about  one-half  inch  higher  than  the  right,  the  outer  border  extend- 
ing about  four  inches  from  the  median  line  of  the  back  (Figs.  62  and  65). 
The  ureters  correspond  on  the  anterior  surface  of  the  body  to  a  line 
drawn  almost  vertically  in  the  umbilical  region  from  the  hilus  of  each 


208  THE    ABDOMEN. 

kidney  about  one  and  a  half  inches  from  the  median  line  (see  Fig.  59). 
After  crossing  the  external  iliac  arteries,  they  pass  gradually  toward  the 
median  line  in  the  pelvis.  According  to  Morris,  the  surface  marking 
of  the  ureter  on  the  anterior  surface  of  the  abdomen  is  as  follows :  The 
upper  point  where  the  ureter  passes  into  the  pelvis  of  the  kidney  is  at 
the  intersection  of  a  transverse  line  between  the  tips  of  the  twelfth  ribs 
with  a  vertical  line  drawn  upward  from  the  junction  of  the  inner  and 
middle  third  of  Poupart's  ligament.  The  lower  point,  where  it  crosses 
the  iliac  artery,  is  at  the  junction  of  the  upper  and  middle  thirds  of  the 
line  of  the  common  and  external  iliac  arteries,  namely,  three-fourths  of 
an  inch  below,  and  to  the  left  of  the  umbilicus,  to  a  point  midway  be- 
tween the  anterior  superior  spine  of  the  ilium  and  the  symphysis  pubis. 

The  relations  of  the  deeper  abdominal  viscera  to  the  posterior 
surface  of  the  body  can  be  understood  from  Figs.  62  and  65.  The  right 
lobe  of  the  liver  extends  upward  as  high  as  the  level  of  the  angle  of  the 
scapula  (eighth  rib).  The  spleen  and  fundus  of  the  stomach  extend  on 
the  left  side  to  the  eighth  interspace,  the  central  tendon  of  the  diaphragm 
(esophagus,  etc.)  reaches  up  to  the  eighth  dorsal  spine,  the  esophagus 
lying  here  to  the  left  of  the  median  line.  The  right  lobe  of  the  liver 
is  covered  posteriorly  by  the  right  lung  as  far  as  a  line  drawn  horizon- 
tally outward  from  the  tenth  dorsal  spine,  and  the  right  lobe  of  the  liver 
is  covered  by  the  reflection  of  the  pleura  at  the  level  of  a  line  drawn 
horizontally  outward  from  the  eleventh  vertebra.  The  right  lobe  of  the 
liver  is  seen  to  be  in  contact  with  the  kidney  and  hepatic  flexure  of  the 
colon.  The  left  lobe  is  in  contact  with  the  spleen.  The  right  kidney  is 
seen  to  be  in  contact  with  the  hepatic  flexure  of  the  colon,  the  left  kid- 
ney with  the  spleen  and  splenic  flexure  of  the  colon.  The  cardiac  orifice 
of  the  stomach  lies  one  inch  to  the  left  of  the  ninth  dorsal  spine. 

The  Skin. 

The  skin  of  the  abdomen  is  very  movable  upon  the  deeper  tissues, 
except  around  the  umbilicus.  In  large  tumors  or  in  collections 
of  fluid  within  the  abdomen  or  during  pregnancy  the  skin  is  greatly 
stretched,  causing  so-called  striae  to  appear,  in  the  fresh  condition  as 
bluish,  in  older  ones  as  silvery  streaks,  due  to  a  breaking  of  the  elastic 
tissue  of  the  skin.  Beneath  the  skin  is  the  subcutaneous  tissue  or  super- 
ficial fascia,  which  may  be  divided  into  two  layers;  the  outer  contains  the 
bulk  of  the  subcutaneous  fat  of  the  region.  The  deeper  layer  is  firmer, 
more  membranous  in  character.  It  is  continuous  with  the  aponeurosis  of 
the  external  oblique  in  the  linea  alba,  at  Poupart's  ligament,  and  at  the 


Fig.  63. — Relations  of  gall-bladder,  duodenum,  and  pancreas  i,  Gall-bladder 
in  situ.  2,  Cystic  artery;  a  branch  of  the  hepatic  artery.  3,  Hepatic  artery.  4,  Hepatic 
duct.  5,  Portal  vein.  6,  Pancreatic  duct.  7,  Common  duct,  opening  at  papilla  of  Vater. 
8,  Cystic  duct.  P,  Pancreas.  D,  Duodenum. 


209 


Fig.  64. — Relations  of  duodenum,  pancreas,  kidneys,  and  spleen,  i,  Aorta.  2, 
Vena  cava  inferior.  3,  Esophagus.  4,  Splenic  artery.  5,  Right  ureter.  6,  Left  ureter. 
R.K.,  Right  kidney.  L.K.,  Left  kidney.  D,  Duodenum.  P,  Pancreas.  S,  Spleen. 


211 


Fig.  65. — Surface  markings  of  pleurae,  lungs,  interlobar  fissures,  and  relations  of 
pleural  cavity  to  the  kidneys  (seen  from  behind),  i,  Apical  and  posterior  mediastinal 
pleura.  2,  Upper  and  posterior  margins  of  lungs.  3,  Interlobar  fissures  between  upper 
and  lower  lobes  on  both  sides.  4,  Lower  border  of  lung.  5,  Lower  border  of  pleura. 
6,  Left  kidney.  7,  Right  kidney.  Upon  the  right  side  observe  a  short  twelfth  rib,  as 
not  infrequently  occurs,  lying  entirely  within  the  pleural  cavity.  Upon  the  left  side  the 
ribs  are  shown  in  the  normal  or  average  length  (see  text).  8,  Ascending  colon.  9, 
Transverse  colon.  10,  Descending  colon,  n,  Iliac  colon.  12,  Pelvic  colon — n  and  12 
are  usually  described  as  the  sigmoid  flexure.  13,  Rectum  and  anal  canal.  The  extra- 
peritoneal  portions  of  the  ascending  and  descending  colon  and  rectum  are  represented 
by  the  finely  dotted  areas.  DS,  Left  dome  of  diaphragm.  DR,  Right  dome  of  dia- 
phragm. SP,  Spleen.  14,  Cecum.  15,  Beginning  of  ileum.  16,  Appendix. 


213 


THE    ABDOMINAL    WALLS.  215 

crest  of  the  ilium.  In  the  interval  between  the  symphysis  and  the  pubic 
spine — i.  e.,  around  the  external  abdominal  ring — it  has  no  attachment, 
but  is  continuous  with  the  deep  fascia  of  the  scrotum  (dartos).  Ex- 
travasated  urine  can  escape  to  the  surface  of  the  abdomen  through  this 
interval,  but  will  be  limited  by  the  attachments  of  the  deep  layer  of 
fascia  to  Poupart's  ligament,  from  escaping  to  the  thigh.  Between  the 
two  layers  of  the  superficial  fascia  lie  the  vessels,  nerves,  and  lymphatics 
which  supply  the  skin  of  the  abdomen. 

The  vessels  are  the  superficial  epigastric  and  the  superficial  circum- 
flex iliac  arteries  and  veins  (branches  of  the  femoral  artery  and  vein)  in 
the  lower  half,  and  the  anterior  and  posterior  intercostals  above  (branches 
of  internal  mammary  and  thoracic  aorta)  (see  Fig.  50).  In  cases  of 
obstruction  in  the  portal  or  abdominal  circulations  (e.  g.,  cirrhosis  of  the 
liver,  aneurisms  of  aorta,  etc.)  these  vessels  assist  the  deeper  ones  of  the 
abdominal  wall  (see  below)  in  establishing  a  collateral  circulation.  The 
superficial  lymphatics  of  the  skin  of  the  upper  half  empty  into  the 
axillary,  those  of  the  lower  half  into  the  inguinal  glands  (see  Figs.  52 
and  53). 

The  Abdominal  Walls. 

The  anterior  abdominal  walls  vary  greatly  in  thickness.  This  vari- 
ation is  dependent,  first,  upon  the  amount  of  subcutaneous  fat,  and, 
secondly,  upon  the  development  of  the  abdominal  muscles.  They  may 
be  so  thin,  especially  in  children,  that  the  contours  of  the  hollow  viscera 
may  be  seen  through  them,  and  this  fact  is  often  used  to  observe  the 
so-called  "  peristaltic  wave."  In  cases  of  pyloric  or  intestinal  obstruc- 
tion a  visible  wave  of  this  kind,  traveling  in  an  opposite  direction  to 
the  normal  one,  is  of  great  diagnostic  value.  It  indicates  a  stenosis  or 
narrowing  of  the  lumen,  and  is  called  an  antiperistaltic  wave. 

The  chief  muscles  of  the  anterior  abdominal  walls  are  the  external 
and  internal  oblique,  transversalis,  and  rectus  on  each  side.  The  ex- 
ternal oblique  arises  chiefly  from  the  eight  lower  ribs  and  crest  of 
ilium;  its  fibers  run  down  and  inward,  ending  in  a  broad  aponeurosis 
which  passes  across  the  front  of  the  rectus  to  the  median  line,  assisting 
the  aponeurosis  of  the  internal  oblique  in  forming  its  anterior  sheath  (see 
Figs.  66  and  75).  The  lower  portion  forms  the  greater  part  of  Poupart's 
ligament,  and  divides  opposite  the  pubic  spine  to  form  the  external  ab- 
dominal ring  (Fig.  66),  the  portion  attached  to  the  pubic  spine  being 
called  the  inner  pillar,  that  attached  to  the  horizontal  ramus  the  outer 
pillar.  The  fibers  arching  across  the  ring  between  the  two  pillars  are 
called  the  intercolumnar  fibers  or  external  spermatic  fascia. 


2l6  THE    ABDOMEN. 

The  Internal  Oblique. — Arises  from  the  three  lower  ribs,  crest  of 
the  ilium,  and  the  outer  half  of  Poupart's  ligament ;  its  fibers  run  up  and 
inward,  and  terminate  in  an  aponeurosis  which  divides  at  the  outer  border 
of  the  rectus  (linea  semilunaris)  into  an  anterior  layer,  which  unites  with 
the  aponeurosis  of  the  external  oblique  to  form  the  anterior  sheath  of  the 
rectus,  and  a  posterior  layer  which  passes  behind  the  rectus  to  form  its 
posterior  sheath  (see  Figs.  66  and  74).  Midway  between  the  umbilicus 
and  symphysis  pubis  (see  Fig.  67)  both  layers  of  the  internal  oblique 
gradually  pass  in  front  of  the  rectus,  forming  only  its  anterior  sheath,  so 
that  the  rectus  is  separated  from  the  peritoneum  here  by  the  transversalis 
fascia  only.  The  lower  fibers  of  the  internal  oblique  are  continued  over 
the  spermatic  cord  as  the  cremaster  muscle  (Fig.  68).  The  fibers  of  the 
internal  oblique  which  arise  from  Poupart's  ligament  unite  with  those  of 
the  transversalis,  forming  the  conjoined  tendon  to  be  inserted  into  the 
crest  and  spine  of  the  pubes  in  front  of  the  rectus. 

The  Transversalis. — Arises  from  the  inner  surface  of  the  lower  six 
costal  cartilages,  from  the  crest  of  the  ilium,  and  outer  third  of  Poupart's 
ligament,  and  from  the  anterior  or  inner  lamella  of  the  lumbar  fascia 
(Fig.  76).  Its  fibers  pass  transversely  across  the  median  line,  ending  in 
a  broad  aponeurosis  which  passes  behind  the  rectus  in  its  upper  two- 
thirds;  but  midway  between  the  umbilicus  and  pubis  it  passes  in  front 
of  it  with  the  external  and  internal  oblique.  Its  inner  surface  is  cov- 
ered by  the  transversalis  fascia,  which  separates  the  muscle  from  the 
parietal  peritoneum,  being  very  thin  above,  but  very  strong  below  the 
umbilicus.  It  joins  with  the  internal  oblique  to  form  the  conjoined 
tendon  (Figs.  67  and  77). 

The  Rectus. — Arises  from  the  ensiform  process  and  fifth,  sixth,  and 
seventh  costal  cartilages;  its  fibers  pass  directly  downward  to  be  inserted 
into  the  upper  surface  of  the  symphysis  pubis.  Its  sheath  is  formed  by 
the  other  abdominal  muscles,  as  given  above;  namely,  in  its  upper  three- 
fourths  by  the  external  oblique  and  anterior  layer  of  the  internal  oblique 
aponeurosis  in  front  and  the  posterior  layer  of  the  internal  oblique  and 
transversalis  behind  (Fig.  74).  In  the  lower  one-fourth  of  the  linea 
alba  the  sheath  is  very  strong  in  front,  having  the  aponeuroses  of  all  three 
muscles  (external  and  internal  oblique  and  transversalis),  but  compara- 
tively weak  behind,  consisting  only  of  the  transversalis  fascia  and  peri- 
toneum (see  Fig.  77). 

The  Transversalis  Fascia. — This  layer  above  the  umbilicus  is 
scarcely  of  sufficient  thickness  to  be  called  a  membrane;  below  the  navel 
it  becomes  quite  thick  and  firm,  forming  an  aponeurosis  which  serves  as  a 
posterior  sheath  to  the  rectus,  and  takes  the  place  there  of  the  internal 


Fig.  66. — Topography  of  inguinal  and  femoral  hernial  regions  (superficial  layers). 
A.Sp.,  Anterior  superior  spine  of  ilium.  I.C.,  Inguinal  canal,  shown  in  dotted  outline. 
At  its  lower  end  (external  abdominal  ring)  the  spermatic  cord  is  seen  to  emerge.  At  its 
upper  end,  corresponding  to  the  dotted  circle,  is  situated  the  internal  abdominal  ring  (a 
little  above  the  middle  of  Poupart's  ligament).  E.O.,  External  oblique  muscle,  whose 
aponeurosis  divides  to  form  the  external  abdominal  ring.  I.O.,  Internal  oblique  muscle, 
showing  its  attachment  to  outer  half  of  Poupart's  ligament;  toward  the  median  line  its 
aponeurosis  is  shown,  uniting  with  that  of  the  external  oblique.  F,  Femoral  vein.  P, 
Poupart's  ligament.  I.S..  Internal  saphenous  vein.  F.O.,  Fossa  ovalis,  covered  by  crib- 
riform fascia.  I.F.,  Outer  layer  of  iliac  fascia  forming  the  falciform  border. 


M 


217 


VEINS   OF   THE  ABDOMINAL   WALL.  2IQ 

oblique.  Between  the  external  and  internal  oblique  and  transversalis 
muscles  there  is  loose  connective  tissue,  favoring  the  spread  of  abscesses 
and  extravasations  of  blood  between  them.  The  abdominal  muscles  are 
powerful  expiratory  muscles,  and  exert  a  positive  pressure  upon  the 
abdominal  contents  during  expiration ;  hence,  stab  wounds  are  irregular 
and  gape  during  inspiration.  For  the  same  reason  it  is  difficult  to 
secure  rest  for  the  wounds  of  the  abdominal  wall,  and  there  is  a  greater 
disposition  to  the  formation  of  herniae  after  operations. 

The  Linea  Alba. 

This  corresponds  to  the  point  of  union  of  the  abdominal  muscles  in 
the  median  line  (see  Fig.  67).  It  is  widest  just  above  the  umbilicus, 
being  eighteen  to  twenty  millimeters  here;  while  below  the  same  it  grad- 
ually decreases,  being  only  two  millimeters  wide  above  the  symphysis 
pubis.  It  is  widened  during  pregnancy  or  when  an  abdominal  tumor  is 
present,  causing  diastasis  or  separation  of  the  recti  muscles,  so  that  the 
hand  can  often  be  placed  between  the  recti.  It  has  many  openings  for 
blood-vessels  and  nerves;  these  may  become  enlarged  and  favor  the  for- 
mation of  a  hernia.  Such  herniae  of  the  linea  alba  must  not  be  con- 
founded with  lipomata,  which  can  occur  in  the  median  line,  and  which 
may  give  rise  to  symptoms  like  those  of  a  hernia,  even  of  incarceration. 
The  parietal  peritoneum  is  firmly  adherent  to  the  linea  alba  and  um- 
bilicus; lateral  to  it,  it  has  considerable  subserous  fat. 

Deep  Arteries  of  the  Abdominal  Wall. 

In  the  upper  portion  of  the  abdominal  wall  these  are  derived  from 
the  last  intercostals  and  lumbar  arteries;  in  the  lower  portion  from  the 
deep  epigastric  branch  of  the  external  iliac  artery.  The  latter  is  of 
considerable  importance  in  the  surgical  anatomy  of  hernia;  it  lies  be- 
neath the  transversalis  fascia  just  above  Poupart's  ligament  (Figs.  66,  67, 
and  69)  and  then  penetrates  the  sheath  of  the  rectus  muscle.  Its  course 
can  be  described  as  corresponding  to  a  line  drawn  from  the  middle  of 
Poupart's  ligament  to  the  umbilicus.  It  anastomoses  with  the  deep 
superior  epigastric  branch  of  the  internal  mammary. 

The  Veins  of  the  Abdominal  Wall. 

The  superficial  as  well  as  the  deep  veins  anastomose  freely;  those 
supplying  the  lower  half  of  the  abdominal  wall  anastomose  freely  with 
those  of  the  upper  half,  and  also  with  the  vein  which  runs  in  the  liga- 
mentum  teres  or  suspensory  ligament  of  the  liver  into  the  portal  vein. 
Thus  a  collateral  circulation  is  easily  formed  in  cases  of  obstruction  to 


220  THE    ABDOMEN. 

cither  the  vena  cava  or  in  the  portal  circulation.  There  may  be  such 
a  radiation  of  veins  at  times  from  the  umbilicus  as  to  give  rise  to  the 
appearance  of  what  has  been  called  the  caput  medusa?  (see  Fig.  50).  In 
the  Talma-Morison  operation  advantage  is  taken  of  this  fact  to  estab- 
lish a  collateral  circulation  between  the  omentum  and  abdominal  wall 
to  relieve  the  ascites  of  cirrhosis  of  the  liver. 

The  Nerves. 

The  abdominal  muscles  as  well  as  the  skin  of  the  abdominal  wall  are 
supplied  by  the  last  six  intercostals  and  the  first  lumbar  nerve.  This 
is  of  considerable  clinical  importance,  because  any  irritation  of  the  skin 
will  produce  a  reflex  contraction  of  the  abdominal  muscles.  These  nerves 
also  anastomose  freely  with  the  branches  of  the  sympathetic  plexus  (see 
Fig.  91),  so  that  a  blow  upon  the  abdominal  wall  will  not  infrequently 
cause  a  paralysis  of  the  blood-vessels  supplied  by  the  solar  plexus,  re- 
sulting at  times  in  fatal  syncope.  Pleuritic  pain,  especially  if  the  pleurisy 
is  situated  close  to  the  diaphragm  (diaphragmatic  pleurisy),  is  often  re- 
ferred along  the  intercostal  nerves  to  the  abdomen,  and,  similarly,  pres- 
sure upon  the  intercostal  and  lumbar  nerves,  due  to  tuberculosis  or 
tumors  of  the  spine  or  spinal  cord,  will  be  referred  to  the  ends  of  the 
nerves  in  the  abdominal  wall. 

The  nerves  of  the  skin  of  the  trunk  have  still  more  important  asso- 
ciations. The  spinal  segments  with  which  they  are  connected  are  also  in 
communication  with  the  viscera  of  the  abdomen  and  thorax  through  the 
sympathetic  system  (see  Figs.  40  and  70).  Hence,  diseased  conditions  of 
the  abdominal  viscera  give  rise  to  disturbances  in  the  spinal  segments 
with  which  they  are  connected,  and  the  brain,  being  accustomed  to 
localize  pain  along  the  spinal  nerves,  makes  a  mistake  and  refers  the 
pain  along  the  spinal  nerve  of  the  segment  disturbed.  Not  only  is  pain 
referred,  but  the  skin  supplied  by  the  disturbed  spinal  segments  becomes 
tender,  and  through  a  study  of  these,  Head  has  been  able  to  localize 
the  visceral  centers,  thus  affording  the  surgeon  a  means  for  increased 
accuracy  of  location  of  pain  as  a  symptom  in  abdominal  diagnosis. 

The  abdominal  viscera  are  supplied  from  the  sixth  dorsal  to  the  first 
lumbar  segments  of  the  spinal  cord,  the  nerves  passing  to  their  destina- 
tions through  the  rami  communicantes,  splanchnic  nerves,  and  sympa- 
thetic plexuses  of  the  abdomen  (see  Figs.  49,  70,  and  91).  No  -visceral 
nerves  escape  through  the  second,  third,  or  fourth  lumbar  nerves,  hence 
these  are  never  the  seats  of  visceral  referred  pains.  The  pelvic  viscera 
are  supplied  from  the  fifth  lumbar  to  the  third  or  sometimes  fourth  sacral 
nerve  through  the  nervi  erigentes. 


Fig.  67. — Topography  of  inguinal  and  femoral  hernia  (deeper  layers).  Sp.C.,  Sper- 
matic cord,  in  inguinal  canal,  lying  upon  Poupart's  ligament.  Tr.,  Transversalis  muscle, 
attached  to  outer  half  of  Poupart's  ligament,  and  joining  with  internal  oblique  to  form  the 
conjoined  tendon  (W),  which  passes  in  front  of  the  rectus  to  be  attached  to  upper  border 
of  pubis.  A.S.R.,  Anterior  sheath  of  rectus  turned  back,  formed  below  by  aponeurosis 
of  external  oblique  and  conjoined  tendon.  P.,  Poupart's  ligament.  D.E.A.,  Deep  epi- 
gastric artery,  shown  in  outline.  It  lies  between  the  transversalis  fascia  and  peritoneum. 
A.Sp.,  Anterior  superior  spine  of  ilium.  R.I.S.,  Right  rectus,  cut  transversely,  showing 
its  anterior  sheath  and  posterior  sheath  (P.S.R.).  B.L.A.,  Linea  alba,  broad  above  um- 
bilicus, but  narrowing  gradually  toward  pubis.  R.,  Left  rectus,  showing  tendinous  por- 
tions, most  marked  above  umbilicus.  S.P.,  Spine  of  pubis.  An  inguinal  hernia  emerges 
to  the  inner  side  of  it;  a  femoral  to  outer  side  of  it.  G.,  Gimbernat's  ligament.  F.O., 
Femoral  opening.  I.F.,  Iliac  fascia  (outer  layer),  with  its  falciform  border,  across  the 
lower  edge  of  which  the  internal  saphenous  vein  (P.F.)  crosses  to  enter  the  femoral  vein 
(V.).  A.,  Femoral  artery. 

221 


ABDOMINAL    INCISIONS. 


223 


The  following  are  the  segments  with  which  each  viscus  is  connected 
(Figs.  49  and  70) : 


Viscus. 

SPINAL  SEGMENT. 

AREA. 

MAXIMUM   POINTS. 

Esophagus,   car- 
diac end  

Stomach. 

Sixth  Dorsal. 
Seventh  Eighth,  and 

Infrascapulo- 
mammary. 

Subscapulo-en- 

Anterior:    fifth    rib,    one   inch 
internal  to  nipple  line. 
Posterior:  seventh  spine,   one 
and    one-half    inches    from 
mid-line. 
Anterior'    over   ensiform    car- 

Liver  

Ninth  Dorsal. 
Eighth     and     Ninth 

siform. 
Middle    epigas- 

tilage. 
Posterior:    ninth    spine,    from 
this  to  scapular  angle. 
Anterior:    eighth    space,    two 

Gall-bladder  ... 
Kidnev  .... 

Dorsal. 

Ninth  Dorsal. 
Tenth  and  Eleventh 

tric. 

Supra  -umbilical. 
Subumbilical. 

inches  outside  nipple-line. 
Posterior:  one  and  one-half  to 
two  and  one-half  inches  be- 
low angle  of  scapular,  and 
two  to  three  inches  outside 
of  mid-line. 
Anterior:    tip   of  tenth   costal 
cartilage. 
Posterior:  eleventh  dorsal  spine, 
one     and     one-half    inches 
from  mid-line. 
Anterior:    one    and    one-half 

Uterus 

Dorsal. 
Eleventh  Dorsal. 

Gluteo-crural. 

inches  outside  and  one  inch 
below  umbilicus. 
Posterior:  tip  of  twelfth  rib. 
Close  to  great  trochanter. 

Fallopian  tubes. 

Bladder          and 
prostate 

Eleventh  Dorsal. 
Eleventh  Dorsal. 

Sacro-iliac. 
Sacral  area. 

Above,   and  on  inner  side  of 
knee. 
Anterior:  above  Poupart's  liga- 
ment,   at    level    of   internal 
ring. 
Posterior:    fifth    lumbar    and 
first  sacral  spines. 
Anterior:  tip  of  glans  penis. 
Posterior:   over  ischial   tuber- 

osity;  over  lower  sacrum. 

Pain  referred  to  districts  supplied  by  the  lower  abdominal  nerves  in 
connection  with  spinal  caries  may  mislead  the  surgeon  as  to  the  real  seat 
of  the  malady,  and  arouse  a  suspicion  of  mischief  in  the  kidneys  or 
bladder.  Pott's  disease  is  often  referred  to  the  terminal  portions  of  the 
nerve,  especially  over  the  front  of  the  abdomen. 

Abdominal  Incisions. 

The  line  of  incision  for  laparotomy  is  most  frequently  made  in  the 
median  line  along  the  linea  alba,  some  operators  preferring  to  divide 
exactly  through  the  latter,  and  others  laterally  to  it,  through  the  sheath 
of  the  rectus,  either  right  or  left  side.  The  peritoneum  is  quite  firmly 
adherent  to  the  linea  alba,  so  that  great  care  must  be  exercised  in  suturing 


224  THE    ABDOMEN. 

a  wound  in  the  median  line  lest  the  peritoneum  prolapse,  the  edges  of 
the  recti  pull  apart,  and  a  post-operative  ventral  hernia  result.  This 
can  be  avoided  to  a  great  extent  by  bearing  in  mind  the  anatomic  rela- 
tions. 

The  peritoneal  edges  will  usually  approximate  without  much  traction, 
but  it  is  very  difficult  to  avoid  a  hernia  unless  care  is  taken,  in  that  portion 
of  the  linea  alba  which  lies  above  the  junction  of  its  lower  and  middle 
thirds,  to  remember  that  the  anterior  and  posterior  sheaths  of  the  rcctus 
are  of  about  equal  strength  and  both  should  be  pulled  well  forward  to- 
ward the  median  line.  In  the  lower  third  of  the  linea  alba  (see  Fig.  77) 
the  conditions  are  different ;  here,  the  anterior  sheath  of  the  rectus  is  far 
stronger  than  the  posterior,  being  made  up  of  the  combined  aponeuroses 
of  the  external  oblique,  the  internal  oblique,  and  the  transversalis  muscles. 
Hence,  it  is  necessary  to  pull  its  anterior  sheath  well  forward  in  suturing 
either  by  through-and-through  sutures  extending  through  all  the  coats 
of  the  abdominal  wall,  or  in  a  suture  by  layers.  The  posterior  sheath  is 
made  up  simply  of  the  transversalis  fascia,  which  is  usually  well  approxi- 
mated if  the  peritoneum  has  been  brought  into  close  apposition,  being 
firmly  attached  to  the  latter. 

Before  exploration  of  the  gall-bladder  region  the  incision  is  usually 
made  along  the  right  border  of  the  right  rectus,  incising  the  aponeuroses 
of  the  abdominal  muscles  as  they  pass  across  the  rectus  to  form  its  an- 
terior and  posterior  sheaths. 

For  exploration  of  the  right  iliac,  especially  in  appendicitis  operations, 
the  muscles  are  often  divided  in  one  direction, — that  is,  parallel  to  the 
fibers  of  the  aponeurosis  of  the  external  oblique, — care  being  taken  to 
avoid  the  deep  epigastric  artery,  which  lies  between  the  transversalis 
fascia  and  peritoneum,  its  course  being  a  line  drawn  from  about  the 
middle  of  Poupart's  ligament  to  the  umbilicus  (Figs.  66  and  69).  This 
form  of  incision  is  made  through  all  of  the  coats  if  it  is  not  desirable  to 
suture  all  of  the  abdominal  \vall  at  the  time  of  examination;  for  exam- 
ple, in  a  case  of  suppuration,  etc.  On  the  other  hand,  if  it  is  desired  to 
suture  the  abdominal  wound  immediately  and  completely,  the  external 
oblique  is  divided  by  an  incision  carried  obliquely  downward  and  in- 
ward in  the  direction  of  its  aponeurosis,  the  internal  oblique  is  incised 
in  the  direction  of  its  fibers  upward  and  inward,  and  the  transversalis 
in  a  transverse  direction.  Advantage  is  thus  taken  of  the  arrangement 
of  the  muscular  fibers  of  these  three  large  abdominal  muscles,  so  that  the 
best  mechanical  obstacle  to  a  hernia  is  obtained,  the  direction  of  the  in- 
cisions in  each  interfering  with  the  pressure  from  within,  owing  to  the 
fact  that  one  is  placed  almost  at  right  angles  to  the  other. 


INGUINAt    REGION.  225 

To  operate  upon  the  stomach,  the  incision  is  usually  made  along  the 
left  border  of  the  rectus,  close  to  the  costal  arch.  To  open  the  abdomen 
for  the  relief  of  intestinal  obstruction,  if  it  is  desirable  to  establish  an 
artificial  anus,  the  incision  is  made  in  the  left  iliac  region,  in  a  similar 
manner  to  that  made  for  appendicitis  in  the  right  iliac. 

Inguinal  Region. 

The  inguinal  region  and  canal  in  the  male  will  be  first  described. 
The  inguinal  region  of  either  side  has  as  its  boundaries  Poupart's  liga- 
ment, the  median  line,  and  a  line  drawn  from  the  anterior  superior  spine 
of  the  ilium  to  the  umbilicus  (Figs.  66  and  67).  The  layers  in  this  region 
are  (i)  skin  and  superficial  fascia;  (2)  aponeurosis  of  the  external  oblique; 
(3)  internal  oblique  and  transversalis  muscles,  which  are  not  attached  to 
the  inner  half  of  Poupart's  ligament;  (4)  transversalis  fascia;  (5)  sub- 
serous  connective  tissue,  in  which  the  deep  epigastric  artery  and  vein  lie; 
(6)  parietal  layer  of  peritoneum.  The  first  four  are  traversed  by  the 
spermatic  cord  in  an  oblique  direction,  from  without  above,  toward 
the  median  line  below.  The  spermatic  cord  lies  in  the  inguinal  canal. 
There  is  no  true  canal  under  normal  conditions;  it  is  only  open  under 
pathologic  conditions,  when  a  viscus  distends  it.  That  is,  it  is  a  poten- 
tial canal  like  the  urethra,  capable  of  being  distended. 

We  may  describe  an  external  opening,  or  ring,  an  internal  opening, 
or  ring,  and  four  walls.  The  external  opening  is  formed  by  a  split  in 
the  fibers  of  the  external  oblique  aponeurosis,  the  external  abdominal 
ring,  the  two  boundaries  of  the  ring  being  called  the  inner  and  outer 
pillars,  of  which  the  former  is  broader  and  thinner  than  the  latter. 
The  external  ring  is  situated  2  to  3  cm.  (i  inch)  from  the  median  line. 
Its  size  depends  upon  the  intercolumnar  fibers  which  bound  the  ring 
above.  Normally,  one  can  insert  the  tip  of  the  index-finger  into  it  in 
the  adult,  and  the  little  finger  in  the  child.  It  is  largest  when  the  thigh 
is  everted.  The  internal  abdominal  ring  lies  nearly  an  inch  (15 
mm.)  above  Poupart's  ligament,  midway  between  the  symphysis  pubis 
and  anterior  superior  spine  of  the  ilium  (see  Fig.  67). 

The  transversalis  fascia  is  penetrated  and  sends  a  prolongation  into 
the  canal  at  the  edges  of  the  internal  ring,  known  as  the  infundibuliform 
fascia  (Fig.  68),  which  accompanies  the  cord  and  forms  the  tunica  vag- 
inalis  communis  (funiculi  spermatici  et  testis).  The  inguinal  canal  is 
4  to  5  cm.  (ij  to  2  inches)  long;  it  is  traversed  by  the  spermatic  cord, 
which  lies  at  first  behind  the  transversalis  muscle,  then  passes  beneath 
the  free  edge  of  the  transversalis  and  internal  oblique,  to  the  external 
ring  (see  Figs.  66  and  67).  The  anterior  wall  of  the  canal  is  formed 


226  THE    ABDOMEN. 

by  the  external  oblique  aponeurosis  and  by  the  fibers  of  the  internal 
oblique  (in  its  outer  part) ;  the  posterior  wall  is  formed  by  the  conjoined 
tendon  of  the  internal  oblique  and  transversalis  and  the  transversalis 
fascia.  Its  outer  or  lateral  portion  is  strong,  the  inner  or  median  weak, 
hence  favoring  the  development  of  a  hernia.  The  boundary  between 
these  two  portions  of  the  posterior  wall  is  marked  by  the  deep  epigastric 
artery.  The  upper  wall  is  formed  by  the  arching  fibers  of  the  internal 
oblique  and'  transversalis.  The  lower  wall  is  formed  by  Poupart's  lig- 
ament and  at  its  inner  part  by  Gimbernat's  ligament.  When  the  ab- 
dominal wall  is  examined  from  the  inner  side,  a  depression  is  seen  oppo- 
site both  the  external  and  internal  rings;  through  the  former,  the  direct 
hernia  makes  its  way;  through  the  latter,  the  indirect  (see  Fig.  69).  In 
addition  to  the  above  infundibuliform  fascia,  the  spermatic  cord  receives 
as  coverings,  the  cremasteric  fascia  from  the  internal  oblique,  and  inter- 
columnar  or  external  spermatic  fascia  from  the  external  oblique  (see 
Fig.  68). 

Inguinal  Hernia  in  the  Male. — A  hernia  which  develops  by  pass- 
ing through  the  internal  abdominal  ring,  then  traversing  the  entire 
inguinal  canal  and  emerging  at  the  external  ring,  is  called  an  indirect 
oblique  inguinal  hernia.  It  lies,  at  first,  external  to  the  deep  epigastric 
artery.  The  direct  inguinal  hernia  is  one  which  breaks  through  the 
posterior  wall  of  the  inguinal  canal  at  the  depression  corresponding  in- 
ternally to  the  external  ring,  and  pushes  forward  and  appears  at  the  ex- 
ternal ring.  Such  a  direct  hernia  always  lies  internal  to  the  deep  epi- 
gastric artery.  A  rarer  form  of  hernia  is  the  interstitial  hernia,  which 
develops  in  the  inguinal  canal,  pushing  forward  on  to  the  abdominal 
wall  or  between  the  muscles  of  the  same. 

Indirect  Hernia. — Such  a  hernia  enters  with  the  spermatic  cord  at 
the  internal  ring,  the  cord  lying  to  its  inner  side  and  behind.  It  traverses 
the  inguinal  canal  and  passes  through  the  external  ring  into  the  scrotum. 
It  may  be  congenital  or  acquired;  the  former,  from  the  non-closure  of  the 
vaginal  process  of  the  peritoneum,  which  normally  accompanies  the 
spermatic  cord  and  testis  in  its  descent  (see  Fig.  69).  Such  congenital 
herniae  are  most  frequently  developed  after  birth,  when  the  tunica  vag- 
inalis  testis  is  nearly  formed,  and  are  favored  by  the  fact  that  in  children 
the  inguinal  canal  does  not  have  an  oblique  direction,  but  is  almost 
straight  through  the  abdominal  wall.  A  spontaneous  cure  may  occur  in 
such  herniae  through  the  obliteration  of  the  vaginal  process.  A  hernia 
may  develop  in  later  life  in  the  vaginal  process  of  peritoneum,  the  latter 
remaining  pervious  for  many  years,  until  some  sudden  increase  of  intra- 
abdominal  pressure  forces  the  intestine  into  it.  In  the  acquired  type  there 


Fig.  68. — Coverings  of  inguinal  (congenital  and  acquired)  and  of  femoral  herniae. 
(Diagrammatic.)  DE,  Deep  epigastric  artery.  1C,  Internal  abdominal  ring.  E,  Ex- 
ternal abdominal  ring.  F,  Peritoneum  of  both  inguinal  hernial  sacs.  IF,  Infundibuliform 
fascia.  CR,  Cremasteric  fascia.  EO,  Intercolumnar  fascia  (external  spermatic)  from 
external  oblique.  SPC,  Spermatic  cord,  lying  on  outer  side  and  behind  sac.  TV,  Tunica 
vaginalis,  not  seen  on  opposite  side  because  there  is  none  in  a  congenital  hernia,  as  shown 
on  right  side.  A,  Femoral  artery.  V,  Femoral  vein.  F,  Femoral  ring,  through  which 
femoral  hernia  escapes.  P,  Gimbernat's  ligament.  N,  Anterior  crural  nerve.  S, 
Saphenous  opening.  FS,  Peritoneal  sac  of  femoral  hernia.  SC,  Septum  crurale.  CF, 
Cribriform  fascia. 


227 


Fig.  69. — View  of  inside  of  anterior  wall  of  abdomen  to  show  internal  orifices  of 
inguinal,  femoral,  and  obturator  herniae.  DA,  Deep  epigastric  artery.  E,  Middle  in- 
guinal fossa,  corresponding  externally  to  external  abdominal  ring.  A  direct  inguinal 
hernia  passes  directly  outward  through  this  depression  without  traversing  the  inguinal 
canal  from  I  to  E.  This  fossa  is  situated  at  the  lower  portion  of  Hesselbach's  triangle. 
This  triangle  is  formed  by  the  deep  epigastric  artery  on  the  outer  side,  Poupart's  ligament 
below,  and  the  remains  of  the  hypogastric  artery  (H)  and  fold  of  peritoneum  covering  it 
on  the  inner  side.  Between  H  and  U  the  internal  inguinal  fossa  is  to  be  seen.  U,  Re- 
mains of  urachus,  passing  from  anterior  surface  of  bladder  to  umbilicus.  I,  Internal 
abdominal  ring.  Across  its  lower  edge  on  either  side  is  to  be  seen  the  spermatic  artery 
and  vein  (S),  and  the  vas  deferens  (D),  passing  into  the  inguinal  canal,  all  lying  extraperi- 
toneally.  V,  External  iliac  artery  and  vein,  as  they  pass  under  Poupart's  ligament.  F 
Femoral  ring  covered  by  septum  crurale  and  peritoneum  lying  over  it,  through  which  a 
femoral  hernia  emerges  from  the  abdomen.  The  internal  abdominal  ring  is  seen  separated 
from  the  femoral  ring  by  the  deep  epigastric  artery.  O,  Obturator  opening,  through 
which  an  obturator  hernia  escapes  from  the  abdomen.  B,  Superior  surface  of  bladder. 
R,  Rectum. 


229 


Fig.  70. — View  of  distribution  of  sensory  nerves  of  the  skin  according  to  individual  nerves  (shown 
on  the  left  side  of  the  body),  and  of  the  same  areas  in  relation  to  the  segments  of  the  cord  (shown  on 
the  right  side  of  the  body).  G.O.,  Area  of  occipital  major.  Su.Cl.,  Supraclavicular  and  acromial 
branches  of  the  cervical  plexus.  I.C.D.,  Posterior  branches  of  the  intercostal  nerves.  P.D.L.,  Poste- 
rior branches  of  the  lumbar  nerves.  I.Hy.,  Iliohypogastric  area.  C.I.,  Circumflex.  Ic.H.,  Intercosto- 
humeral.  M.Sp.,  Musculospiral.  M.C.,  External  cutaneous  or  musculocutaneous.  I.C.,  Internal 
cutaneous.  R.,  Radial.  U.,  Ulnar.  M.,  Median.  On  the  right  side  of  the  posterior  aspect  of  the 
body  is  seen  the  distribution  according  to  segments  of  the  cord,  C  standing  for  cervical,  D  for  dorsal, 
L  for  lumbar,  and  S  for  sacral  segments  of  the  cord,  respectively.  (See  section  on  Spine.)  From  the 
fifth  to  the  twelfth  dorsal  segments  on  the  right  side,  and  in  the  fourth  sacral  segment  of  the  same  side, 
the  maximum  points,  according  to  Head,  for  the  abdominal  viscera  are  shown.  (See  Abdomen.) 


INGUINAL   REGION.  233 

is  no  preformed  sac.  The  peritoneum  is  simply  pushed  forward  by  the 
viscera  or  omentum.  At  first  there  may  be  only  a  bulging  in  the  inguinal 
canal,  or  at  the  external  ring,  but  sooner  or  later  it  escapes  through  the 
latter  and  passes  along  the  spermatic  cord  into  the  scrotum  (scrotal  or 
complete  hernia)  (see  Fig.  68).  The  shape  of  such  a  hernia  is  frequently 
that  of  a  pear,  and  it  may  attain  an  enormous  size.  In  cases  in  which  the 
duration  of  the  hernia  has  extended  over  a  number  of  years,  the  canal 
itself  may  become  obliterated,  so  that  the  external  and  internal  abdomi- 
nal rings  are  opposite  each  other.  This  variety  is  known  as  the  straight 
hernia.  The  coverings  of  an  indirect  oblique  inguinal  hernia  are  skin, 
deep  fascia  of  Cooper,  intercolumnar  fibers,  cremaster  muscle,  infundib- 
uliform  fascia,  and  peritoneum  (see  Fig.  68).  The  contents  may  con- 
sist only  of  intestines  (enterocele),  or  of  omentum  (epiplocele),  or  both. 
It  may  also  contain  any  one  of  the  more  movable  viscera ;  for  example, 
the  ovary  or  tube,  the  appendix,  and  occasionally  the  bladder.  The 
deep  epigastric  artery  always  lies  to  the  inner  side  of  the  neck  of  the 
sac,  that  is,  the  internal  ring,  the  cord  to  the  inside  and  behind.  An 
indirect  hernia  lies  along  the  outer  edge  of  Hesselbach's  triangle,  which 
latter  is  formed  by  the  outer  border  of  rectus,  inner  third  of  Poupart's 
ligament,  and  deep  epigastric  artery  (see  Fig.  69). 

A  direct  inguinal  hernia  pushes  the  posterior  wall  of  the  canal  for- 
ward at  its  thinnest  part  (at  floor  of  Hesselbach's  triangle),  where  only 
the  conjoined  tendon  of  the  internal  oblique  and  transversalis  muscles 
and  transversalis  fascia  are  present,  at  the  depression  which  corresponds 
internally  to  the  external  ring  (fovea  externa)  (see  Fig.  69).  It  shows 
itself  at  the  outer  border  of  the  rectus,  internal  to  the  deep  epigastric  ar- 
tery, and  presents  externally  at  the  external  ring.  The  sac  forms  as  the 
hernia  develops.  The  hernial  opening  is  usually  quite  large,  admitting 
one  to  two  fingers.  The  cord  lies  to  its  outer  side.  The  form  of  the 
hernia  is  conical,  generally  the  size  of  an  egg.  Its  coverings  are  the 
skin,  deep  fascia,  conjoined  tendon,  transversalis  fascia,  and  peritoneum. 

Strangulation  of  a  hernia  occurs  when  the  contents  are  constricted  so 
that  the  flow  of  blood  in  the  vessels  is  obstructed.  This  rapidly  causes 
intestinal  paralysis,  with  resultant  obstruction  to  the  passage  of  the 
contents  of  the  intestine.  It  is  rare  in  the  direct  form  of  inguinal 
hernia,  but  frequent  in  the  indirect,  occurring  usually  at  the  neck  of  the 
sac,  namely,  at  the  internal  ring.  In  incising  such  a  constriction  the 
relations  of  the  deep  epigastric  artery  must  be  borne  in  mind.  It 
lies  to  the  inner  side  (see  Figs.  67  and  69). 

An  interstitial  hernia  is  one  in  which  the  sac  is  developed  in  the  in- 
guinal canal,  usually  with  ectopia  testis.  It  may  grow  either  between 
15 


234  THE    ABDOMEN. 

the  abdominal  muscles,  or  through  the  external  ring  toward  Poupart's 
ligament. 

Inguinal  Canal  in  the  Female. — On  account  of  the  greater  sep- 
aration of  the  spines  of  the  ilium,  the  canal  is  longer  (5  to  6  cm.)  than 
in  the  male.  The  rings  are  smaller,  and  the  walls  are  closer  together, 
only  transmitting  the  round  ligament.  Hence,  hernia  is  less  frequent 
than  in  the  male.  The  process  of  peritoneum  (canal  of  Nuck)  accom- 
panying the  round  ligament  lies  to  its  inner  side.  In  a  hernia  we  may 
find,  in  addition  to  the  contents  in  the  male,  not  infrequently  the  adnexa. 
An  inguinal  hernia  in  the  female  may  be  either  congenital  or  acquired; 
the  latter  is  more  frequent,  as  a  result  of  the  increased  size  of  the  round 
ligament  during  pregnancy,  and  its  decrease  after  the  same,  leaving 
the  canal  larger.  Such  a  hernia  appears  at  the  upper  end  of  the  labia 
majora. 

The  chief  nerves  which  play  a  role  in  the  anatomy  of  inguinal  hernia 
are  the  last  dorsal  and  two  of  the  branches  of  the  lumbar  plexus,  the 
iliohypogastric  and  the  ilioinguinal  nerves  (Fig.  49).  The  latter  two 
are  the  more  important.  The  iliohypogastric  lies  between  the  trans- 
versalis  and  internal  oblique  above  the  crest  of  the  ilium.  About  an 
inch  in  front  of  the  anterior  superior  spine  it  pierces  the  internal  oblique 
and  continues  its  course  in  the  groin  beneath  the  aponeurosis  of  the  ex- 
ternal oblique.  It  becomes  cutaneous  by  piercing  the  latter  about  an 
inch  above  the  external  abdominal  ring.  The  ilioinguinal  nerve  ac- 
companies the  spermatic  cord.  It  takes  a  course  similar  to  that  of  the 
iliohypogastric,  but  at  a  lower  level.  It  lies  beneath  the  aponeurosis  of 
the  external  oblique  just  above  Poupart's  ligament,  accompanying  the 
spermatic  cord,  and  becomes  superficial  after  passing  through  the  ex- 
ternal abdominal  ring,  and  supplies  the  skin  of  the  uppermost  portion  of 
the  thigh  and  pubic  region. 

Femoral  Region. 

Poupart's  ligament,  or  the  crural  arch,  is  composed  of  an  independent 
fibrous  band  which  extends  from  the  anterior  superior  spine  of  the  ilium 
to  the  pubic  spine,  and  amalgamates  with  the  lower  border  of  the  ex- 
ternal oblique  aponeurosis.  Its  inner  part  forms  Gimbernat's  ligament. 
Beneath  Poupart's  ligament  are  two  openings,  one  on  the  outer  side  for 
the  iliopsoas  muscle  and  anterior  crural  nerve,  and  one  on  the  inner  side 
for  the  femoral  vessels.  These  openings  are  separated  by  the  ilio-pec- 
tineal  ligament  (Fig.  88).  The  vessels  are  inclosed  in  a  sheath  formed  by 
the  extension  of  the  iliac  fascia  (pectineal  fascia)  behind,  and  the  transvcr- 
salis  fascia  (fascia  lata)  in  front  (Fig.  66).  An  open  space  is  left  to  the 


FEMORAL    REGION.  235 

inner  side  of  the  femoral  vein,  which  is  a  fourth  to  half  an  inch  long, 
begins  at  Gimbernat's  opening  and  extends  to  the  saphenous  opening, 
and  is  called  the  crural  canal  (Fig.  67).  The  upper  end  of  this  canal 
(crural  ring)  is  covered  by  peritoneum  and  is  filled  by  a  plug  of  fat  or 
a  lymphatic  gland,  constituting  the  septum  crurale.  The  deep  epigastric 
artery  separates  (Fig.  69)  the  femoral  ring  from  the  internal  abdominal 
ring.  Usually  the  canal  only  contains  a  small  lymph-gland,  and  is,  like 
the  inguinal,  a  potential  canal.  It  is  funnel-shaped  from  the  base  down- 
ward to  its  apex,  which  lies  just  below  Poupart's  ligament  under  the 
saphenous  opening  on  the  inner  side  of  Scarpa's  triangle,  so  that  a 
femoral  hernia  at  first  descends  along  the  crural  or  femoral  canal  until  it 
comes  to  the  saphenous  opening,  and  then  passes  upward  toward  the 
skin  in  the  fold  of  the  groin. 

The  femoral  sheath  is  formed  by  the  union  of  the  fascia  lata  (pec- 
tineal  fascia)  and  the  continuation  of  the  deep  fascia  (transversalis)  of  the 
abdominal  wall  into  the  fascia  lata.  Hence,  a  femoral  hernia  has  lying 
behind  it  the  pectineus  muscle,  being  separated  from  it  by  the  pectineal 
fascia  (see  Fig.  67).  The  anterior  wall  of  the  crural  canal  is  thus  formed 
by  the  superficial  layer  of  the  fascia  lata,  which,  as  stated  above,  is  a  con- 
tinuation of  the  deep  fascia  of  the  abdomen,  being  attached  to  the  outer 
portion  of  Poupart's  ligament.  Its  posterior  wall  is  formed  by  the  deep 
or  inner  layer  of  the  fascia  lata  or  the  pectineal  fascia  (continuation  of 
the  iliac  fascia,  as  stated  above).  The  femoral  hernia  pushes  before  it 
the  peritoneum  and  septum  crurale,  descends  along  the  femoral  canal  for 
a  distance  of  one-fourth  to  one-half  inch,  until  it  comes  to  the  saphenous 
opening.  This  saphenous  opening  is  a  gap  in  the  fascia  lata  (iliac  por- 
tion) which  is  not  well  defined  on  its  inner  side.  It  measures,  vertically, 
one  and  a  half  to  two  inches,  and  is  one  inch  external  to  the  pubic  spine. 
The  outer  edge  of  the  opening  is  well  marked  and  has  a  crescentic  edge 
(falciform  border)  (Fig.  67).  The  internal  saphenous  vein  crosses  over 
its  lower  edge  to  empty  into  the  femoral  vein  (Fig.  48).  The  remainder 
of  the  opening  is  filled  in  by  some  loose  connective  tissue  and  lymphatic 
glands.  When  a  femoral  hernia  has  come  to  the  lower  end  of  its  canal, 
there  is  no  other  course  left  for  it  except  to  bend  forward  toward  the 
skin,  which  it  does  by  escaping  through  the  saphenous  opening,  and  thus 
receives  a  third  covering,  the  cribriform  fascia  (Fig.  68),  which  is  the 
name  given  to  the  above-mentioned  loose  connective  tissue  covering  the 
saphenous  opening.  The  septum  crurale  and  cribriform  fascia  are  often 
imperfectly  formed,  so  that  a  femoral  hernia  may  have  as  its  covering 
only  the  peritoneum,  subserous  fat,  and  skin.  The  point  of  strangulation 


236  THE   ABDOMEN. 

of  this  variety  of  hernia  is  usually  only  at  the  saphenous  opening,  or  at 
the  femoral  ring  at  the  inner  side  of  the  femoral  vein  (Fig.  68). 

An  inguinal  hernia  lies  above  Poupart's  ligament,  a  femoral  hernia 
always  below  it  (Fig.  68).  The  inguinal  hernia  emerges  to  the  inner, 
the  femoral  to  the  outer  side  of  the  pubic  spine.  After  emerging  from 
the  saphenous  opening  a  femoral  hernia  may  pass  toward  Poupart's 
ligament,  so  that  it  is  impossible  to  distinguish  it  from  an  inguinal  with- 
out considering  the  above  points.  The  size  of  the  femoral. canal  is 
greatest  when  the  limb  is  flexed,  adducted,  and  rotated  inward,  so  that 
this  is  the  most  favorable  position  for  the  reduction  of  such  a  hernia. 
Femoral  hernia  is  more  frequent  in  females  than  in  males,  in  a  propor- 
tion of  4  to  i.  It  is  favored  by  repeated  pregnancies. 

Umbilical  Hernia. 

An  umbilical  hernia  may  be  one  of  three  varieties:  (i)  Congenital, 
due  to  non-closure  of  the  opening  in  the  fetus  through  which  the  umbilical 
cord  with  its  vessels  and  remains  of  the  omphalomesenteric  duct  have 
passed  into  the  body;  (2)  the  infantile  variety,  due  to  the  incomplete 
closure  of  the  umbilical  ring;  and  (3)  the  adult  type.  Of  these  three 
varieties,  the  infantile  type  is  by  far  the  most  frequent.  The  first  variety 
is  in  reality  a  congenital  defect,  due  to  non-closure  of  the  abdominal  wall 
at  the  umbilicus.  At  a  certain  stage  of  the  development  of  the  embryo  the 
anterior  abdominal  wall  is  open  in  the  region  of  the  umbilicus,  and  if  this 
fails  to  close,  the  hernia  is  in  reality  an  ectopia,  analogous  to  a  similar 
condition  of  the  bladder,  and  may  contain  almost  any  one  of  the  abdom- 
inal viscera.  Such  a  hernia  is  covered  by  a  thin  layer  of  Wharton's  jelly, 
and  by  a  continuation  of  the  parietal  peritoneum  in  the  form  of  a  thin 
membrane.  The  congenital  umbilical  hernia  may  contain  only  a 
knuckle  of  intestine.  It  is  not  only  of  pathologic  interest,  but  may  be- 
come of  great  importance  if  the  umbilical  cord  is  tied  too  close  to  the 
body  and  a  knuckle  of  intestine  should  be  ligated  with  the  stump. 

The  infantile  type  occurs  especially  in  children  who  are  subject  to 
intestinal  colic  or  constipation,  or  have  phimosis,  or  may  develop  without 
any  of  these  causes,  in  the  following  manner:  Following  the  ligation  of 
the  umbilical  cord  after  birth,  the  stump  dries  up  and  leaves  a  small 
granulating  area  which  is  rapidly  covered  with  skin  from  the  adjacent 
edges.  Whenever  there  is  increase  of  intra-abdominal  pressure,  the  thin 
cicatrix  which  covers  the  umbilical  ring  (as  the  opening  in  the  linea  alba 
is  called  through  which  the  cord  passes)  is  stretched,  and  the  peritoneum 
pushes  the  overlying,  thin,  umbilical  and  transversalis  fascia  and  skin 
before  it.  This  is  especially  apt  to  occur  near  the  upper  margin  of  the 


LATERAL    AND    POSTERIOR    WALLS   OF    THE  ABDOMEN.  237 

umbilical  ring,  where  the  umbilical  vein  enters  and  is  loosely  attached  to 
the  edges  of  the  ring;  so  that  an  umbilical  hernia,  such  as  occurs  in  chil- 
dren, is  in  reality  due  to  the  stretching  of  scar  tissue,  and  is  the  most  favor- 
able for  non-operative  treatment.  Either  pressure  with  a  button  or 
bringing  the  recti  close  together  with  adhesive  plaster  will  cause  the  cica- 
tricial  tissue  to  re-form,  and  result  in  a  healing  of  the  hernia.  Many  of 
these  heal  spontaneously  without  any  treatment,  through  new  formation 
of  cicatricial  tissue  over  the  ring. 

The  umbilical  hernia  of  adults  begins  after  the  umbilical  opening  has 
been  filled  in  by  a  firm  scar  tissue.  It  occurs  especially  in  women  after 
repeated  pregnancies,  and  is  due  to  stretching  and  relaxation  of  the 
abdominal  walls.  It  may  occur  independently  of  disease  in  very  stout 
individuals,  owing  to  the  stretching  of  the  umbilical  ring  through  the 
fat.  They  do  not  occur  through  the  umbilical  opening  itself,  but  lateral 
to  it;  and  have  been  called  paraumbilical  herniae.  The  hernial  ring  in 
these  cases  is  usually  very  firm.  The  coverings  consist  of  the  peritoneum, 
transversalis  fascia,  and  skin.  Most  frequently  its  contents  consist  of 
omentum,  which  becomes  firmly  adherent  to  the  interior  of  the  hernial 
sac,  as  occasionally  occurs  in  scrotal  herniae.  The  adherent  omentum 
may  divide  the  sac  into  a  number  of  loculi  or  chambers. 

This  variety  of  umbilical  hernia  in  adults  is  especially  apt  to  become 
strangulated,  owing  to  the  firm  fibrous  character  of  the  ring  and  the 
intimate  relation  of  its  contents  to  the  sac.  An  anatomic  point  not  to  be 
forgotten  in  the  treatment  of  all  varieties  of  hernia  which  contain  a  large 
amount  of  omentum  and  intestine  (this  is  especially  true  of  umbilical 
hernia)  is  that  in  stout  individuals  with  a  short  thorax  the  replacement 
of  the  contents  of  such  a  hernia  into  the  abdominal  cavity  often  causes 
serious  interference  with  the  action  of  the  diaphragm,  giving  rise  to  fatal 
pulmonary  conditions,  the  abdominal  cavity  not  being  able  to  accommo- 
date itself  rapidly  to  the  largely  increased  contents. 

Lateral  and  Posterior  Walls  of  the  Abdomen. 

The  lateral  and  posterior  walls  of  the  abdomen  include  the  region  of 
the  iliac  fossae  and  the  lumbar  region. 

Region  of  the  Iliac  Fossa. — Both  lateral  and  posterior  regions  of  the 
abdomen  are  lined  by  one  continuous  fascia,  which  receives  different 
names  according  to  the  region.  Along  the  lateral  and  posterior  walls  of 
the  abdomen  the  firm  fascia  which  lies  between  the  peritoneum  and  the 
muscles  of  the  lateral  abdominal  wall  (external  oblique,  internal  oblique, 
and  transversalis)  is  called  the  transversalis  fascia.  Above,  the  transver- 
salis fascia  is  continuous  with  the  firm  fascia  which  lines  the  under  surface 


238  THE    ABDOMEN. 

of  the  diaphragm.  At  the  outer  border  of  the  quadratus  lumborum  mus- 
cle, the  transversalis  fascia  is  continued  over  the  anterior  surface  of  this 
muscle  as  a  thin  layer,  forming  the  anterior  layer  of  the  lumbar  fascia 
(see  Figs.  74  and  75).  At  the  crest  of  the  ilium  the  transversalis  covers 
the  iliopsoas  muscle,  and  is  here  called  the  iliac  fascia.  The  iliac  fascia 
really  begins  with  the  psoas  muscle  in  the  lumbar  vertebrae,  and  covers 
the  psoas  until  it  joins  with  the  iliacus,  accompanying  the  iliopsoas 
muscle  to  the  lesser  trochanter  (Figs.  71  and  87).  It  is  attached  to  the 
inner  border  of  the  crest  of  the  ilium,  and  internally  to  the  brim  of  the 
true  pelvis  along  the  iliopectineal  line.  The  portion  covering  the  psoas 
is  attached  above  to  the  ligamentum  arcuatum  internum  and  to  the  bodies 
of  the  lower  dorsal  and  lumbar  vertebrae. 

Along  the  posterior  wall  of  the  abdomen  a  third  fascia  plays  a  role— 
the  lumbar  fascia  (Fig.  74).  This  fascia  divides  into  three  layers — an 
anterior,  a  middle,  and  a  posterior.  It  is  attached  internally  to  the 
spinous  processes  of  the  lumbar  and  sacral  vertebrae.  The  posterior 
layer  forms  the  aponeurosis  of  the  latissimus  dorsi.  The  anterior 
layer  covers  the  anterior  surface  of  the  quadratus  lumborum  and  is 
continued  as  the  transversalis  fascia.  The  middle  layer,  which  covers 
the  posterior  surface  of  the  quadratus  lumborum,  is  continued  into  the 
transversalis  muscle  (Figs.  74  and  75).  The  upper  portion  of  the  most 
anterior  of  these  layers  constitutes  the  ligamentum  arcuatum  ex- 
ternum  (Fig.  71). 

A  knowledge  of  the  disposition  of  these  fasciae,  and  the  fact  that  they 
are  continuous  with  each  other,  are  of  considerable  clinical  importance 
for  the  following  reasons: 

First :  An  abscess  or  extravasation  of  blood  between  the  transversalis 
fascia  and  the  abdominal  muscles  is  usually  checked  anteriorly  and 
below  at  Poupart's  ligament  and  the  crest  of  the  ilium,  and  behind  at  the 
anterior  border  of  the  quadratus  lumborum.  Owing  to  the  fact,  as 
stated  above,  that  one  of  the  ligaments  of  the  diaphragm  (ligamentum 
arcuatum  externum)  is  formed  by  the  lumbar  fascia,  an  empyema  may 
occasionally  rupture,  or  work  its  way  through  the  diaphragm  or  along  this 
ligament,  and  appear  between  the  last  rib  and  the  crest  of  the  ilium  as  a 
fluctuating  tumor  whose  posterior  boundary  is  the  anterior  edge  of  the 
quadratus  lumborum. 

Second :  In  the  same  manner  an  appendiceal  abscess  may  travel  up- 
ward to  the  extraperitoneal  tissue  lying  between  the  muscular  structure 
of  the  diaphragm  and  the  thick  fascia  separating  it  on  its  under  surface 
from  the  peritoneum,  giving  rise  to  the  extraperitoneal  form  of  subphrenic 
abscesses.  The  lumbar  fascia  being  continuous  with  the  transversalis 


LATERAL    AND    POSTERIOR   WALLS    OF    THE    ABDOMEN.  239 

fascia  and  transversalis  muscle,  pus  from  the  sacro-iliac  joint,  from 
the  bodies  of  the  vertebrae,  from  the  retroperitoneal  lymph-glands,  or 
from  the  kidney,  may  penetrate  this  fascia  and  travel  to  the  surface 
between  the  iliac  crest  and  last  rib;  or,  through  the  communication  of 
this  fascia  with  that  portion  of  the  iliac  fascia  which  covers  the  iliopsoas 
muscle,  may  open  in  addition  above  or  below  Poupart's  ligament,  or 
even  work  its  way  at  the  iliopectineal  line  beneath  the  pelvic  fascia, 
around  the  pelvic  viscera  toward  the  outlet  of  the  pelvis  (see  Fig.  90). 

The  iliac  fascia  is  but  loosely  attached  (see  Figs.  74  and  75)  to  both 
the  psoas  and  iliacus.  A  considerable  amount  of  fluid  may  collect  be- 
tween these  muscles  and  their  fascia.  A  tubercular  abscess  due  to  dis- 
ease of  the  last  dorsal  or  upper  lumbar  vertebra  along  which  the  psoas  is 
attached,  gravitates  downward  to  the  iliac  fossa,  being  limited  at  the  brim 
of  the  pelvis  and  the  crest  of  the  ilium  by  the  attachments  of  the  fascia. 
It  usually  dissects  under  the  fascia  to  the  attachment  of  the  muscle  to  the 
lesser  trochanter  (Fig.  128).  Owing  to  the  fact  that  the  iliac  fascia  com- 
municates at  the  brim  of  the  pelvis  with  the  pelvic  fascia,  abscesses  be- 
neath the  latter,  arising  from  the  parametrium  in  the  female,  or  from  the 
prostate  or  rectum  in  the  male,  may  dissect  up  the  pelvic  fascia  until 
they  arrive  at  the  brim  of  the  true  pelvis,  when  they  pass  into  the 
cellular  tissue  either  between  the  iliac  fascia  and  the  iliopsoas  muscle 
or  between  the  fascia  and  the  peritoneum,  which  is  loosely  connected 
with  the  fascia  lining  the  iliac  fossa,  and  appear  above  Poupart's  liga- 
ment, where  they  can  be  opened. 

Abscesses  arising  from  the  appendix  may  rupture  into  the  extra- 
peritoneal  tissue  of  the  iliac  fossa,  dissecting  between  it  and  the  iliac 
fascia  toward  the  kidney,  or  toward  the  lateral  or  anterior  walls  of  the 
abdomen. 

The  remaining  points  of  clinical  interest  in  the  iliac  and  lumbar 
regions  are  the  following : 

The  iliac  fossa  contains  the  iliac  artery  and  vein,  the  iliac  glands,  the 
spermatic  vessels  (see  Figs.  77  and  88),  and  is  crossed  by  the  ureter. 
The  peritoneum  can  be  easily  stripped  from  the  iliac  fascia  here,  so 
that  the  surgeon  can  work  in  this  space  with  ease.  The  iliac  glands 
receive  lymph  from  the  inguinal  glands  situated  just  above  Poupart's  liga- 
ment, so  that  a  deep-seated  suppuration  may  occur  secondary  to  an  in- 
fection of  the  inguinal  glands  in  the  iliac  fossa  (Fig.  52).  These  can  be 
best  drained  in  the  same  manner  as  the  method  of  ligation  for  the  ex- 
ternal  iliac  artery,  by  making  an  incision  parallel  to  Poupart's  ligament 
through  the  abdominal  muscles  and  pushing  the  peritoneum,  which  can 
be  easily  stripped  from  the  iliac  fascia,  inward.  In  the  interval  between 


240  THE   ABDOMEN. 

the  iliac  fascia  and  the  iliacus  muscle,  abscesses  from  disease  of  the  ver- 
tebrae may  lie,  as  stated  above,  passing  along  under  Poupart's  ligament 
to  the  lesser  trochanter.  In  this  layer  also  lie  the  anterior  crural  nerve 
and  external  cutaneous  nerve  (Fig.  88). 

The  genitocrural  nerve  lies  on  the  psoas  muscle  on  the  outer  sides  of 
the  common  iliac  vessels.  Its  genital  branch  enters  the  inguinal  canal  at 
the  internal  abdominal  ring,  supplying  the  skin  of  the  sacrum.  The 
crural  branch  continues  with  the  psoas  into  the  thigh,  supplying  the  skin 
over  Scarpa's  triangle  external  to  that  supplied  by  the  ilio-inguinal. 

The  obturator  nerve  lies  in  the  iliac  fossa  for  a  short  distance  close  to 
the  pelvic  brim  near  the  inner  border  of  the  psoas,  and  then  follows  along 
the  pelvic  brim  to  the  obturator  foramen,  through  which  it  reaches  the 
thigh,  supplying  the  knee-joint  and  hip-joint  (see  Lower  Extremity). 

In  the  lumbar  region  the  skin,  like  that  of  the  iliac  region,  is  thick 
and  firm.  The  latissimus  dorsi  muscle  lies  quite  superficially.  At  the 
crest  of  the  ilium  there  is  a  small  triangular  space  between  it  and  the  in- 
ternal oblique,  through  which  a  hernia  may  arise;  this  is  the  triangle  of 
Petit.  The  kidney  rests  upon  the  quadratus  lumborum,  separated  only 
by  a  subserous  fat  layer  and  the  very  thin  anterior  layer  of  the  lumbar 
fascia  (the  continuation  of  the  transversalis  fascia,  see  above),  so  that,  in 
order  to  expose  the  kidney,  the  incision  can  be  made  either  parallel  with 
the  outer  border  of  the  quadratus  lumborum  from  the  last  rib  to  the  crest 
of  the  ilium,  or  parallel  to  the  last  rib,  dividing  the  posterior  ends  of  the 
anterior  abdominal  muscles  (internal  oblique  and  transversalis)  and  in- 
cising the  transversalis  fascia  (see  Figs.  74  and  75). 

The  veins  on  the  right  side  of  the  lumbar  region  lead  into  the  vena 
azygos,  on  the  left  side  into  the  vena  hemiazygos.  In  case  of  obstruc- 
tion of  the  iliac  vein,  aneurism,  etc.,  they  form  anastomoses  with  the 
branches  of  the  femoral  vein  on  the  outer  side  of  the  hip  and  lower 
portion  of  the  abdomen  and  establish  a  collateral  circulation.  The 
lymphatics  of  the  skin  empty  into  the  glands  along  Poupart's  ligament. 

The  nerves  supplying  the  muscles  of  the  lateral  and  posterior  abdom- 
inal wall  are  branches  of  the  last  five  dorsal  and  first  two  lumbar  nerves. 
They  lie  between  the  muscles,  giving  off  three  branches  similar  to  the 
intercostal  nerves,  one  posterior,  one  lateral,  and  one  anterior,  sup- 
plying the  skin  of  the  entire  abdominal  wall  and  pubic  region,  as  well 
as  the  muscles  themselves  (Fig.  49).  Hence,  any  irritation,  whether  a 
blow,  or,  in  general,  any  form  of  sensory  stimulation,  whether  heat,  cold, 
tactile,  etc.,  will  cause  a  reflex  contraction  of  the  muscles  of  the  abdominal 
wall;  and,  on  account  of  the  connection,  as  stated  above,  of  these  lower 
intercostal  and  lumbar  nerves  with  the  sympathetic  ganglia  supplying  the 


THE    ABDOMINAL    CAVITY    IN    GENERAL.  241 

viscera,  pain  in  the  latter  is  referred  to  the  corresponding  point  in  the 
abdominal  wall  supplied  by  the  same  spinal  segment. 

This  reflex  contraction  of  the  abdominal  muscles  and  their  mechan- 
ical arrangement  at  right  angles  to  each  other,  serves  as  the  best  protec- 
tion to  the  viscera  from  external  violence,  except  such  violence  as  may 
come  so  suddenly  as  to  render  a  contraction  impossible.  If  a  blow  is 
directed  toward  the  skin  of  the  abdomen,  the  reflex  contraction  of  the 
muscles  forms  a  fairly  firm  barrier  against  the  force. 

The  Abdominal  Cavity  in  General. 

This  represents  the  largest  serous  cavity  of  the  body.  In  males  it  has 
no  communication  with  the  external  world ;  in  females  it  has  such  commu- 
nication through  the  Fallopian  tubes  and  uterus.  The  entire  cavity  is 
lined  by  peritoneum  (parietal),  which  at  certain  places  (situated  especially 
along  the  posterior  wall)  is  reflected  upon  the  viscera,  forming  one  of 
their  coats  (visceral  peritoneum).  Other  reflections  serve  as  ligaments 
to  suspend  the  organs,  giving  them  a  varying  degree  of  range  of  motion. 

The  viscera  which  are  partly  covered  by  peritoneum,  and  thus  be- 
come to  some,  extent  extraperitoneal,  are  the  duodenum  and  pancreas, 
lower  portion  of  rectum,  bladder,  and  vagina.  The  kidneys,  suprarenal 
capsules,  ureters,  and  abdominal  vessels  all  lie  outside  of  the  peritoneum, 
but  inside  of  the  abdominal  cavity. 

The  liver,  spleen,  and  female  genitalia  are  rather  firmly  fixed  by  re- 
duplications of  the  parietal  peritoneum  (ligaments)  and  have  only  a 
slight  range  of  motion.  The  spleen  is  more  mobile  than  the  liver  on  ac- 
count of  the  greater  length  and  elasticity  of  its  ligaments. 

The  reduplications  or  reflections  of  parietal  peritoneum  which  sus- 
pend the  hollow  viscera,  forming  the  alimentary  canal,  permit  in  general 
of  a  greater  range  of  motion.  This  is  especially  true  of  the  jejunum, 
ileum,  transverse  colon,  and  sigmoid  flexure  (iliac  and  pelvic  colon). 
On  the  other  hand,  the  duodenum,  ascending  and  descending  colon,  and 
bladder  are  not  completely  covered  by  peritoneum,  and  are  more  fixed. 

The  stomach  resembles  the  more  solid  viscera,  like  the  spleen  and 
liver,  in  having  only  a  comparatively  slight  range  of  motion,  depending 
to  a  great  extent  upon  the  dilatability  of  its  walls,  to  accommodate  the 
varying  quantity  of  its  contents. 

The  peritoneum  has  a  very  rich  nerve  and  lymphatic  supply.  The 
nerves  are  derived  chiefly  from  the  lower  dorsal  and  lumbar  (spinal) 
and  from  the  sympathetic  nerves  (Fig.  91).  The  surface  dimension  of 
the  peritoneum  is  as  great  as  that  of  the  skin  of  the  entire  body.  It  fol- 
lows, therefore,  that  a  blow  upon  the  abdomen  may  cause  a  temporary 


242  THE    ABDOMEN. 

paralysis  of  the  vasoconstrictor  nerves  and  permit  nearly  all  of  the  blood 
of  the  body  to  collect  in  the  vessels  of  the  subserous  layer  of  the  peri- 
toneum. The  parietal  peritoneum  is  far  more  sensitive  to  pain  than  the 
visceral,  and,  according  to  Lennander,  but  little  pain  is  felt  until  the 
parietal  peritoneum  has  been  involved  in  an  inflammatory  process. 

Many  lymphatics  lie  in  the  subserous  connective  tissue,  beneath  the 
endothelial  cells  of  which  the  peritoneum  is  composed.  They  are  pres- 
ent in  the  form  of  interstitial  lymph-spaces  surrounding  the  cells,  and 
pass  directly  over  into  the  lymph-capillaries,  being  well  marked  in  the 
central  tendon  of  the  diaphragm,  where  the  greatest  amount  of  absorp- 
tion occurs.  The  stomata  or  openings  between  the  cells,  which  com- 
municate with  the  above-referred-to  interstitial  lymph-spaces,  are  largest 
there.  Ten  per  cent,  of  a  dog's  weight  can  be  absorbed  by  the  perito- 
neum in  thirty  minutes. 

The  peritoneum,  in  addition  to  the  power  of  absorption,  has  the 
equally  important  property  of  forming  plastic,  adhesive  exudates  which 
become  rapidly  organized,  forming  firm  adhesions.  These  two  faculties 
enable  it  to  limit  the  spread  of  infection,  by  walling  it  off  and  by  ab- 
sorbing it. 

Under  normal  conditions  there  is  no  peritoneal  cavity,  in  the  same 
manner  as  one  cannot  speak  of  a  pleural  cavity.  There  is  usually  only  a 
capillary  space  left  between  the  viscera,  filled  by  a  small  amount  of  fluid 
which  facilitates  peristalsis.  The  parietal  peritoneum  is  not  firmly  at- 
tached to  the  underlying  fasciae,  except  along  the  linea  alba,  and  here 
especially  around  the  umbilicus.  Beneath  it,  in  places,  there  are  consid- 
erable masses  of  fat.  The  attachment  is  so  loose  that  it  enables  the 
bladder,  when  full,  to  push  the  layer  of  peritoneum  covering  its  fundus 
upward  two  inches,  so  that  the  anterior  bladder  wall  can  be  opened 
(suprapubic  cystotomy)  without  opening  the  general  peritoneal  cavity. 

These  divisions  of  the  visceral  peritoneum  in  the  form  of  omenta, 
mesenteries,  and  ligaments,  with  the  aid  of  the  spinal  column,  divide  the 
peritoneal  cavity  into  a  number  of  different  spaces,  which  are  of  great 
interest  from  a  clinical  standpoint.  First,  the  suspensory  ligament  of  the 
liver  and  spinal  column,  down  to  the  promontory  of  the  sacrum,  divide 
it  into  a  right  and  a  left  half.  It  is  also  divided  horizontally  by  the  trans- 
verse colon  with  its  mesocolon  and  omentum,  especially  when  the  latter 
is  drawn  up  into  an  upper  and  a  lower  part.  The  upper  part  contains  the 
stomach,  liver,  upper  portion  of  the  duodenum,  pancreas,  and  spleen. 
The  lower  portion  contains  the  small  intestine  from  the  duodeno-jejunal 
flexure  to  the  ascending  and  descending  colon,  the  rectum,  and  the 
pelvic  viscera. 


,\ 


Fig.  71. — View  of  pelvic  viscera  (male)  and  retroperitoneal  structures.  PE,  Reflec- 
tion of  peritoneum  covering  superior  surface  of  bladder.  R,  Extraperitoneal  space  above 
pubes  when  bladder  is  full.  U,  Ureters.  PC,  Pelvic  colon.  1C,  Iliac  colon,  forming 
with  PC  what  was  formerly  called  the  sigmoid  flexure.  DC,  Descending  colon,  i, 
Testis  with  epididymis,  lying  horizontally.  Normally  it  lies  vertically.  2,  Spermatic 
cord.  On  the  right  side  the  spermatic  vessels  and  vas  deferens  are  seen  free;  on  the 
left  side  they  lie  under  the  peritoneum  at  the  brim  of  the  pelvis.  3,  Inferior  vena  cava. 
The  right  spermatic  vein  is  seen  arising  upon  its  right  side,  near  the  kidney;  left  spermatic 
arises  from  the  renal  vein.  4,  Aorta,  at  point  where  spermatic  arteries  are  given  off.  5, 
Aorta,  just  above  celiac  axis.  6,  Is  placed  just  above  the  superior  mesenteric  artery. 
7,  Inferior  mesenteric  artery.  8,  External  iliac  artery  and  vein,  as  they  pass  beneath 
Poupart's  ligament.  The  anastomosis  can  be  seen  between  the  deep  circumflex  iliac 
and  lumbar  veins.  9,  Pouch  between  bladder  and  rectum.  To  the  left  of  the  figure  9  is 
the  cavity  of  the  pelvis.  10,  Spermatic  artery  and  vein,  n,  Eleventh  rib.  12,  Twelfth 
rib. 


243 


THE    ABDOMINAL    CAVITY    IN   GENERAL.  245 

The  roof  of  the  abdominal  cavity  is  formed  by  the  diaphragm.  Be- 
neath the  diaphragm  there  is  a  right  and  a  left  subphrenic  (Figs.  39  and 
61)  space  formed  by  the  suspensory  or  falciform  ligament  of  the  liver  and 
by  the  spine.  These  right  and  left  subphrenic  spaces  are  again  incom- 
pletely divided  by  the  coronary  ligaments  into  an  anterior  and  a  posterior 
compartment.  In  close  relation  with  the  left  subphrenic  space  (see  Fig. 
61)  is  the  left  lobe  of  the  liver,  stomach,  and  pancreas;  also  the  lesser 
peritoneal  cavity,  splenic  flexure  of  colon,  and  spleen  intraperitoneally, 
as  well  as  the  left  suprarenal  capsule  and  kidney  extraperitoneally. 
Diseases  of  the  stomach  and  pancreas  may  lead  to  abscess  of  the  lesser 
peritoneal  cavity,  which  communicates  behind  the  hepato-duodenal  liga- 
ment with  the  general  peritoneal  cavity  through  the  foramen  of  Winslow. 
The  right  subphrenic  space  is  in  direct  relation  with  the  liver,  and  through 
a  space  lying  behind  the  lower  portion  of  the  right  lobe  of  the  liver  (retro- 
hepatic  space)  in  close  relation  with  the  upper  portion  of  the  duodenum 
and  gall-bladder.  The  right  subphrenic  space  is  also  in  relation  with  the 
right  iliac  fossa  along  the  outer  side  of  the  ascending  colon  (see  Fig.  71). 

This  right  subphrenic  space  can  be  best  drained  through  an  incision 
at  the  posterior  portion  of  the  right  lumbar  region. 

In  that  portion  of  the  abdominal  cavity  which  lies  below  the  trans- 
verse colon  one  can  distinguish  a  central  median  portion  containing  part 
of  the  small  intestines  and  the  omentum,  as  well  as  the  two  lateral  re- 
gions. The  latter  embrace,  on  each  side,  an  iliac  fossa  and  a  lumbar 
region,  with  the  portions  of  small  intestine  and  colon  corresponding  to 
them,  as  well  as  the  kidney  of  that  side.  The  central  portion  is  incom- 
pletely separated  into  a  small  right  and  a  much  larger  left  space,  by  the 
attachment  of  the  mesentery  (left  side  of  second  lumbar  vertebra  to 
right  sacro-iliac  joint).  Both  central  and  lateral  portions,  below  the 
transverse  colon,  communicate  with  the  pelvis. 

In  the  male  pelvis  one  can  only  speak  of  a  single  fossa,  which  is  cap- 
able of  containing  coils  of  intestine  and  fluid  (rectovesical)  (Fig.  83); 
while  in  females  there  are  two — the  rectouterine,  which  is  quite  deep,  and 
the  rectovesical  (Fig.  86). 

In  an  upright  position,  or  when  the  body  of  the  person  is  bent  for- 
ward, all  parts  of  the  peritoneal  cavity  can  drain  toward  the  pelvis  ex- 
cept the  lesser  peritoneal  cavity.  When  a  person  is  lying  down,  pillows 
placed  under  the  back  facilitate  drainage  of  fluid  toward  the  pelvis. 
The  tendency  at  the  present  time,  in  the  drainage  of  intraperitoneal 
septic  fluids  which  it  is  desired  to  have  conveyed  externally,  is  based  upon 
the  above  anatomic  fact;  that  is,  sitting  the  patient  as  nearly  upright  as 
possible.  It  has  been  proposed  by  some  to  elevate  the  pelvis  and  allow 


246  THE    ABDOMEN. 

the  large  lymphatics  spoken  of  above,  which  lie  in  the  diaphragm,  to 
carry  off  the  septic  fluid.  This  has  been  abandoned  to  a  great  extent,  on 
account"  of  the  great  danger  of  intoxication. 

The  most  frequent  points  of  origin  of  a  peritonitis  are  either 
the  alimentary  canal  or  the  genital  tract,  especially  of  the  female.  Of  all 
the  organs  of  the  abdomen,  the  appendix  is  most  frequently  the  cause. 
In  general,  the  causes  in  the  alimentary  canal  are:  (i)  the  perforation  of 
an  ulcer,  due  to  some  disease;  (2)  a  phlegmon  of  the  coats,  with  migration 
of  bacteria  through  the  walls;  (3)  ulcers  situated  above  points  of  stenosis 
(decubitus);  (4)  traumatic  perforation;  (5)  perforation  of  congenital 
diverticula  (Meckel's);  (6)  strangulation  due  to  any  form  of  intestinal 
obstruction;  (7)  embolism,  thrombosis,  or  injury  of  the  mesenteric 
vessels  (see  below) ;  (8)  on  the  part  of  the  liver,  abscesses  and  suppurating 
echinococcus  cysts;  (9)  all  forms  of  pancreatitis;  (10)  cholecystitis  and 
cholangitis;  (n)  puerperal  and  non-puerperal  infections  of  the  female 
genitals,  the  former  being  due  to  streptococci  and  the  latter  to  gonococci ; 

(12)  embolic  abscesses  or  suppurating  echinococcus  cysts  of  the  spleen; 

(13)  infection  of  the  mesenteric  lymphatics;  (14)  secondary  to  abscesses 
of  the  kidney;  (15)  abscesses  of  the  prostate  and  periurethral  abscesses; 
(16)  transmission  through  the  diaphragm  from  the  pericardium  and 
pleural  cavities;  (17)  secondary  to  injuries  and  diseases  of  the  abdominal 
wall;  (18)  secondary  to  infection  of  the  umbilical  cord  in  the  new-born; 
(19)  as  a  complication  of  pylephlebitis,  which  latter  is  secondary  to  an 
infection  of  the  viscera. 

The  peritoneum  can  be  described  as  consisting  of  two  bags  or  sacs,  a 
greater  in  front  and  a  lesser  behind,  connected  by  an  opening,  the  fora- 
men of  Winslow.  The  greater  sac  is  made  up  of  two  layers,  the  parietal 
and  the  visceral. 

The  parietal  lines  the  anterior,  lateral,  and  posterior  walls  of  the 
abdomen.  Between  it  and  the  fasciae  lining  these  parts  there  is  con- 
siderable areolar  tissue  in  which  the  vessels,  nerves,  and  lymphatics  de- 
scribed above  lie.  In  places  this  subserous  tissue  contains  considerable 
fat  (anterior  wall).  The  peritoneum,  through  the  aid  of  its  subserous 
tissue,  is  loosely  attached,  except  along  the  median  line,  so  that  it  can  be 
easily  lifted  up  by  collections  of  fluid  (pus  or  blood).  That  pus  can 
burrow  beneath  it  in  all  directions  is  especially  the  case  in  the  iliac  fossae 
and  lumbar  regions,  where  considerable  amounts  of  fluid  may  accumu- 
late beneath  it. 

When  the  parietal  peritoneum  reaches  the  inferior  aspect  of  the 
diaphragm,  it  is  reflected  upon  it,  and  from  this  point  the  visceral 
peritoneum  can  be  followed  (see  Fig.  72). 


Diaphragm 

Liver 
Lesser  omentum 

Stomach 

Lesser  peritoneal 
cavity 


Transverse  meso- 
colon. 


Transverse  colon 


Omentum 


Small  intestines  (jej- 
unum and  ileum) 


Full  bladder 
Prostate 

Prostatic  urethra 
Pubes 


Pendulous  urethra 

Tunica  vaginalis 

Fossa  navicularis 

Testis 


Subphrenic  space 
Liver  (caudate  lobe) 


Pancreas 


First  lumbar 
vertebra 


Duodenum 


.  Retroperitoneal 

/  space 

—  Mesentery 


Peritoneal  cavity 


Rectov  esical  pouch 


Ampulla  of  rectum 

Seminal  vesicles 
Seminal  duct 
Prostate 

Membranous  urethra 


Anal  canal 


Bulb  of  urethra 

Fig.   72. — Sagittal  section    of  abdomen  in   median   line  to  show  distribution  of    peri- 
toneum (modified  from  Spalteholz). 


247 


THE    ABDOMINAL   CAVITY    IN   GENERAL.  249 

The  visceral  peritoneum  can  be  best  understood  by  following  it  in  a 
vertical  section  made  in  the  median  line  of  the  body  (see  Fig.  72)  and  in  a 
number  of  horizontal  sections  of  the  abdomen  made  at  different  levels 
(Figs.  75  to  78  inclusive).  A  study  of  these  sections  will  show  the  re- 
flections of  the  visceral  peritoneum  to  be  in  the  form  of  mesenteries, 
omenta,  and  ligaments. 

A  mesentery  means  a  double  fold  of  peritoneum  attaching  a  portion 
of  intestine  to  the  posterior  abdominal  wall. 

An  omentum  is  a  fold  connecting  the  stomach  to  the  liver  (gastro- 
hepatic  or  lesser  omentum),  to  the  transverse  colon  (gastrocolic),  and  to 
the  spleen  (gastrosplenic).  A  ligament  connects  an  organ  with  the 
abdominal  parietes. 

In  a  vertical  section  from  above  down,  the  peritoneum  forms  the 
following  reflections  (Fig.  72): 

1.  Coronary  ligaments  (reflection  from  diaphragm  to  liver),  which  are 
continued  on  each  side  as  the  lateral  ligaments  of  the  liver. 

2.  Covers  liver  (except  at  posterior  surface  for  about  two  inches), 
and  is  reflected  from  inferior  surface  of  liver  to  lesser  curvature  of 
stomach,  forming — 

3.  Gastrohepatic  or  lesser  omentum — now  covers  entire  stomach,  and 
then  these  two  layers  are  reflected  from  the  greater  curvature  to  form — 

4.  Gastrocolic  or  greater  omentum — in  conjunction  with  two  layers 
reflected  from  the  spine  covering  the  transverse  colon  (transverse  meso- 
colon). 

5.  Behind  the  stomach,  the  four  layers  composing  the  greater  omen- 
tum separate  to  form  the  lesser  peritoneal  cavity,  which  communicates 
with  the  greater  cavity  through  the  foramen  of  Winslow. 

6.  Below  the  attachment  of  the  mesocolon  the  peritoneum  is  again 
reflected  upon  the  small  intestine  (jejunum  and  ileum).     The  length 
of  the  mesentery  is  eight  inches  at  its  longest  parts. 

In  addition  to  the  above,  there  are  a  number  of  ligaments — phreno- 
colic,  hepatoduodenal — which  cannot  be  seen  in  a  median  section.  In 
the  vertical  and  horizontal  sections  (Figs.  72,  74,  75,  and  76)  the  peri- 
toneum can  be  seen  to  cover  the  anterior  surfaces  of  the  duodenum  and 
pancreas,  to  be  reflected  (after  lining  the  inside  of  the  abdominal  wall) 
upon  the  ascending,  descending,  iliac,  and  pelvic  colon  (sigmoid  flexure), 
forming  a  mesocolon.  Its  pelvic  portion  forms  a  covering  for  the 
bladder  and  rectum  in  the  male,  and  for  the  bladder,  uterus,  and 
rectum  in  the  female.  The  peritoneum  will  be  referred  to  again  in 
connection  with  the  individual  viscera. 

16 


250  THE    ABDOMEN. 

The  Liver. 

The  liver  is  divided  into  two  lobes  by  a  reflection  of  the  parietal 
peritoneum  lining  the  abdominal  wall,  called  the  falciform  or  suspensory 
ligament  (see  Figs.  73  and  74).  If  this  ligament  is  cut,  better  access  can 
be  obtained  for  operations  on  the  superior  surface  of  either  lobe.  The 
liver  is  suspended  from  the  diaphragm  by  a  reflection  of  the  peritoneum 
lining  the  under  surface  of  that  muscle  called  the  coronary  ligament'. 
The  right  lobe  of  the  liver  occupies  the  right  dome  of  the  diaphragm, 
and  the  left  occupies  the  center  of  the  diaphragm,  extending  as  far  under 
the  left  dome  as  the  mid-clavicular  line  (Fig.  39).  As  was  stated  above",' 
there  is  direct  communication  between  the  subphrenic  space,  lying  be- 
tween the  inferior  surface  of  the  diaphragm  and  the  upper  surface  of  the 
right  lobe  of  the  liver,  and  the  general  peritoneal  cavity.  This  space  is 
known  as  the  right  subphrenic  space,  and  is  not  infrequently  the  seat  of 
abscesses  following  appendicitis,  liver  abscesses,  etc.  The  right  lobe  of 
the  liver  lies  entirely  behind  the  ribs,  being  in  contact  with  the  diaphragm, 
and  separated  from  the  thoracic  cavity  by  this  muscle.  The  relations  of 
the  pleura  to  the  right  lobe  are  of  interest.  The  apex  of  the  convexity 
of  the  right  lobe  extends  as  high  as  the  fourth  interspace  (Fig.  61). 
From  this  point  down,  the  greater  portion  of  the  entire  convexity  of  the 
right  lobe  is  in  contact  with  the  lower  and  middle  lobes  of  the  right 
lung  and  with  the  diaphragmatic  pleura,  so  that  abscesses  either 
within  the  right  lobe  of  the  liver  or  between  it  and  the  diaphragm 
frequently  cause  an  empyema  through  perforation  into  the  pleural 
cavity,  or  they  may  give  rise  to  an  abscess  of  the  lung  through 
perforation  into  the  usually  adherent  right  lung  (Figs.  61  and  73). 
On  its  anterior,  posterior,  and  lateral  surfaces  the  pleura  extends 
down  as  far  over  the  liver  as  the  seventh  rib  in  the  mid-clavicular 
line,  the  lower  border  of  the  ninth  costal  cartilage  in  the  axillary  line,  and 
the  lower  border  of  the  eleventh  rib  (at  about  its  middle)  in  the  scapular 
line  (Fig.  62).  It  thus  becomes  necessary  at  times,  in  order  to  explore 
or  drain  both  the  subphrenic  space  on  the  right  side  and  the  right  lobe 
of  the  liver,  to  enter  the  pleural  cavity  (transpleural  drainage).  The 
left  lobe  is  far  more  accessible  through  an  abdominal  incision  than  the 
right  lobe.  The  right  lobe  is  in  close  relation  posteriorly  with  the  right 
kidney,  and  the  descending  portion  of  the  duodenum,  as  well  as  the 
hepatic  flexure  of  the  colon  (see  Figs.  62  and  74).  The  left  lobe  is  in 
relation  with  the  left  kidney,  and  with  the  pancreas  (see  Figs.  62  and  75), 
and  ascending  portion  of  the  duodenum.  It  also  covers  the  greater  por- 
tion of  the  stomach,  being  connected  with  it  by  the  gastrohepatic  or  lesser 
omentum.  Abscesses  of  the  left  lobe  of  the  liver  may  rupture  into  the 


Fig-  73- — Cross-section  of  lower  portion  of  thorax  and  uppermost  portion  of  abdomen, 
at  level  of  tenth  dorsal  vertebra.  RL,  Right  lobe  of  liver.  LL,  Left  lobe  of  liver.  H, 
Hepatic  vein.  V,  Vena  cava  inferior,  lying  within  liver  substance.  A,  Aorta.  T, 
Thoracic  duct.  G,  Esophagus.  S,  Spleen.  D,  Costophrenic  sinus,  showing  the  arching 
character  of  the  diaphragm,  whose  cut  edge  lies  to  the  inner  side  of  the  letter  D.  P, 
Lower  end  of  pericardial  cavity.  LT,  Ligamentum  teres  or  suspensory  ligament  of  liver. 


25' 


Fig.  74. — Cross-section  of  abdomen  at  level  of  middle  of  kidneys  and  liver  (first 
lumbar  vertebra).  S,  Spleen.  LK,  Left  kidney.  RK,  Right  kidney.  QL,  Quadratus 
lumborum  muscle.  CE,  Nerves  of  cauda  equina  projecting  from  spinal  canal.  P,  Pan- 
creas. V,  Stomach,  close  to  cardiac  orifice.  D,  Thoracic  duct.  T,  Ligamentum  teres 
or  suspensory  ligament  of  liver.  LL,  Left  lobe  of  liver.  LF,  Longitudinal  fissure  of 
liver.  RL,  Right  lobe  of  liver,  i,  Aorta.  2,  Vena  cava  inferior.  3,  Gastrohepatic 
or  lesser  omentum.  4,  Gastrosplenic  omentum. 


253 


THE    LIVER.  255 

left  subphrenic  space,  or,  through  adhesions  with  the  diaphragm,  into  the 
left  pleural  cavity.  In  children  the  liver  is  relatively  larger  than  in  adults 
and  occupies  a  large  part  of  the  abdomen  (see  Fig.  58). 

On  the  inferior  surface  of  the  right  lobe  is  the  gall-bladder,  which  is 
usually  quite  firmly  adherent  to  it.  Its  position  may  change  with  the  size 
of  the  liver,  but,  in  general,  it  may  be  said  to  be  opposite  the  ninth  right 
costal  cartilage,  at  its  junction  with  the  right  rectus  muscle  (Fig.  63). 
The  gall-bladder  is  supplied  by  a  branch  of  the  hepatic  artery,  called 
the  cystic  artery  (Figs.  63  and  79).  This  enters  the  gall-bladder  close 
to  its  neck,  and  may  give  rise  to  a  severe  hemorrhage,  if  severed.  The 
position  of  the  gall-bladder  with  relation  to  the  abdominal  wall  can  be  best 
understood  from  figures  61,  63,  and  75.  It  will  be  seen  that  the  fundus 
is  at  a  lower  level  than  the  neck.  The  cystic  duct  has  a  rather  tortuous 
course,  and  in  its  interior  it  has  a  number  of  valve-like  folds  of  mucous 
membrane,  known  as  Heister's  valves,  which  prevent  an  exploration  of  the 
cystic  duct  from  the  fundus  with  the  sound.  At  the  inferior  surface  of 
the  liver  (transverse  fissure)  the  cystic  and  hepatic  ducts  join  at  an  acute 
angle  to  form  the  common  duct.  They  lie  in  the  hepatoduodenal  liga- 
ment, on  the  upper  side  of  the  foramen  of  Winslow.  The  common  duct 
is  described  below  in  connection  with  the  duodenum.  The  hepatic  duct 
is  in  close  proximity  to  the  hepatic  artery,  which  enters  the  liver  close  to 
the  point  of  emergence  of  the  hepatic  ducts  for  the  right  and  left  lobes. 
At  this  point  one  also  finds  the  portal  vein  lying  obliquely  from  right  to 
left  (Fig.  79).  All  of  these  structures  lie  behind  and  above  the  pylorus. 

Gall-stones  may  occur  in  the  hepatic  ducts,  either  within  or 
external  to  the  liver,  in  the  gall-bladder  proper,  or  in  the  cystic  or 
common  ducts.  They  may  lie  dormant  in  the  gall-bladder  throughout 
life,  without  giving  rise  to  any  symptoms,  but,  as  Riedel  has  pointed  out, 
any  infection  of  a  gall-bladder  containing  gall-stones  gives  rise  to  the 
collection  of  a  large  amount  of  serum  within  the  organ,  and  causes  an 
attack  of  cholecystitis  (gall-stone  colic),  with  expulsive  efforts  on  the  part 
of  the  musculature  of  the  gall-bladder — which,  in  the  majority  of  cases, 
are  unsuccessful — to  expel  the  stone  through  the  cystic  duct  into  the 
common  duct.  The  gall-bladder  narrows  toward  the  cystic  duct,  and 
there  are  often  diverticula  here  in  which  stones  are  lodged.  The  cystic 
duct  will  seldom  permit  a  stone  of  larger  caliber  than  a  small  pea  to  pass 
through  it.  The  stones  in  the  common  duct,  through  obstruction  to  the 
flow  of  bile,  cause  either  intermittent  attacks  of  jaundice  through  a  ball- 
valve  action,  as  pointed  out  by  Fenger,  or  a  more  or  less  severe  and  per- 
manent jaundice  through  chronic  obstruction  to  the  flow  of  bile.  Gall- 
stones in  the  gall-bladder  seldom  give  rise  to  jaundice,  and,  if  so,  only 


256  THE    ABDOMEN. 

slight  (inflammatory).  As  stated  below,  a  gall-stone  lodged  near  the 
common  opening  of  the  pancreatic  and  common  bile-ducts  may  give  rise 
to  an  inflammation  of  the  pancreas  (Fig.  80).  The  constant  presence  of 
the  stones  as  irritants  is  not  infrequently  the  starting-point  of  a  carcinoma 
of  the  gall-bladder  or  of  the  bile-ducts. 

A  catarrhal  inflammation  of  the  duodenum  may  occlude  the  orifice  of 
the  common  bile-duct  at  the  ampulla  of  Vater  and  also  give  rise  to  re- 
tention jaundice  (catarrhal  icterus).  Micro-organisms  are  less  abun- 
dant in  the  duodenum  than  in  any  other  portion  of  the  intestinal  tract, 
increasing  in  number  from  this  point  downward.  Nevertheless,  under 
certain  conditions  colon  or  typhoid  bacilli  may  wander  upward  along  the 
bile-passages,  and  give  rise  to  an  inflammation  of  the  gall-bladder  or 
inflammations  of  the  intrahepatic  bile-passages  (angiocholitis).  These 
inflammations  may  be  either  catarrhal  or  suppurative;  if  the  latter,  they 
give  rise  to  multiple  abscesses  within  the  liver.  The  liver  receives  blood 
from  the  stomach,  spleen,  small  and  large  intestines  through  the  portal 
vein,  so  that  any  suppurative  condition  in  these  viscera  (appendicitis, 
dysenteric  colitis,  etc.)  may,  through  an  intervening  inflammation  and 
thrombosis  of  the  corresponding  branch  of  the  portal  vein  (pylephle- 
bitis),  give  rise  to  metastatic  abscesses  in  the  liver  (Fig.  79). 

The  Stomach. 

The  stomach  lies  in  the  left  hypochondriac  and  epigastric  regions. 
It  is  fixed  to  the  diaphragm  through  the  medium  of  the  esophagus,  and  to 
the  liver  through  the  medium  of  the  lesser  omentum  and  hepatoduodenal 
ligament,  which  is  the  continuation  of  the  gastrohepatic  or  lesser  omen- 
tum; lastly,  through  the  medium  of  the  duodenum,  it  is  anchored  to  the 
spinal  column. 

The  stomach  is  divided,  for  convenience,  into  the  cardia,  or  car- 
diac end,  which  lies  close  to  the  opening  of  the  esophagus;  into 
the  fundus,  which  extends  about  an  inch  above  the  cardiac  end  and 
partly  fills  the  left  dome  of  the  diaphragm  (Figs.  61  and  62);  into  the 
body  of  the  stomach  proper,  which  includes  the  greater  portion  of  the 
anterior  and  posterior  walls  with  the  greater  and  lesser  curvatures;  and, 
lastly,  into  the  pyloric  portion,  the  latter  being  situated  in  the  neighbor- 
hood of  the  sphincter  muscle,  which  marks  the  passage  of  the  stomach 
into  the  duodenum. 

Only  the  pylorus  and  half  of  the  greater  curvature  lie  free  and  un- 
covered in  apposition  with  the  anterior  abdominal  wall.  The  remainder 
is  covered  by  the  left  lobe  of  the  liver  (see  Figs.  61  and  74)  and  by  the  ribs, 
being  separated  from  the  chest-wall  by  the  diaphragm,  left  lung,  and 


Fig-  75- — Cross-section  at  level  of  second  lumbar  vertebra.  G,  Fundus  of  gall- 
bladder. L,  Right  lobe  of  liver.  D,  Vertical  portion  of  duodenum  (second  portion). 
DJ,  Jejunum  close  to  duodenojejunal  flexure.  SC,  Splenic  flexure  of  colon,  seen  twice, 
because  the  two  limbs  ran  parallel.  RK,  Right  kidney.  LK,  Left  kidney.  O,  Omen- 
turn.  P,  Psoas  muscle.  QL,  Quadratus  lumborum.  CE,  Nerves  of  cauda  equina, 
hanging  out  of  spinal  canal,  i,  Abdominal  aorta.  2,  Inferior  vena  cava.  3,  Coils  of 
small  intestine  cut  transversely.  Their  relation  to  the  omentum  is  to  be  noted.  These 
coils  are  probably  portions  of  the  jejunum.  4  and  5,  Renal  vessels.  6,  Peritoneal  cavity. 
During  life  such  a  space  does  not  exist,  the  omentum  and  liver  being  in  direct  contact  with 
the  parietal  peritoneum.  The  peritoneum  (white  line)  should  be  followed  to  the  right 
and  left  from  this  point.  7,  Left  rectus  muscle.  In  this  portion  of  the  abdomen  note  the 
formation  of  its  anterior  and  posterior  sheaths  (see  text)  by  the  external  oblique  (10),  in- 
ternal oblique  (9),  and  transversalis  muscles  (8).  On  the  left  side  the  abdominal  muscles 
of  the  anterior  abdominal  wall  should  be  followed  backward,  where  their  relation  to  the 
lumbar  fascia  can  be  studied. 


257 


THE    STOMACH.  259 

pleura  as  far  downward  as  the  seventh  rib  in  the  mid-clavicular  line. 
The  fundus  is  in  close  relation  under  the  left  dome  of  the  diaphragm  with 
the  pericardium  (see  Figs.  39  and  6i),so  that  when  distended  it  pushes  the 
left  half  of  the  diaphragm  upward,  and  can  readily  interfere  with  the  per- 
fect action  of  the  heart,  and  thus  a  flatulent  dyspepsia  may  cause  the 
patient  to  believe  that  he  has  heart  disease.  Behind  the  stomach,  at  the 
lower  portion  of  its  posterior  wall,  the  pancreas  lies,  along  the  upper 
border  of  which  runs  the  large  splenic  artery  from  right  to  left  (see 
Figs.  64,  74,  and  79).  This  relation  explains  the  possibility  of  an  erosion 
of  this  artery  through  an  ulcer  on  the  posterior  wall  of  the  stomach. 

On  account  of  the  relation  of  the  posterior  wall  of  the  stomach  to  the 
lesser  peritoneal  sac  (forming  its  anterior  wall),  the  contents  of  the 
stomach  may  escape  after  perforation  of  the  posterior  wall  into  this  sac 
(Fig.  72),  and  either  become  encapsulated  here,  or  take  one  of  two 
courses :  through  the  foramen  of  Winslow,  which  lies  close  to  the  pylorus, 
into  the  general  peritoneal  cavity,  or  toward  the  left  subphrenic  space, 
abscesses  arising  from  the  stomach  being  one  of  the  most  frequent  causes 
of  left-sided  subphrenic  abscess. 

The  anterior  wall,  as  stated  above,  is  covered  to  a  considerable  extent 
by  the  left  lobe  of  the  liver.  The  cardiac  portion  is  quite  deeply  situ- 
ated, and  not  readily  accessible.  The  pyloric  portion  lies  in  the  epigas- 
tric region  about  one  inch  to  the  right  of  the  median  line,  at  a  point  about 
midway  between  the  ensiform  process  and  umbilicus.  When  empty,  the 
stomach  has  a  far  more  vertical  position  than  was  formerly  thought. 
The  lesser  curvature  of  the  empty  stomach  runs  obliquely  downward  from 
left  to  right.  The  greater  curvature  passes  obliquely  from  the  left  above 
to  the  right  below.  As  the  stomach  fills,  both  of  these  become  more 
horizontal,  so  that  when  the  stomach  is  full  the  greater  curvature  lies 
horizontally  at  a  point  about  two  inches  above  the  umbilicus  (Fig.  61). 

The  stomach  even  under  normal  conditions  may  extend  as  far  as  the 
umbilicus,  but  if  it  extends  below  it,  one  of  two  conditions  is  present: 
either  the  stomach  has  fallen  in  its  entirety,  both  lesser  and  greater  curva- 
tures being  at  a  lower  level  than  normal — a  condition  called  gastroptosis, 
or  falling  of  the  stomach,  due  to  relaxation  of  the  ligaments  holding  it  in 
place ;  or,  secondly,  a  condition  known  as  dilatation  of  the  stomach  exists, 
in  which  the  lesser  curvature  remains  at  approximately  its  normal  level, 
whereas  the  greater  curvature  is  at  a  much  lower  one,  even  extending  at 
times  to  the  symphysis  pubis  in  extreme  conditions.  Such  dilatation  is 
usually  due  to  an  obstruction  at  the  pylorus. 

The  average  capacity  of  the  stomach  is  1500  cubic  centimeters,  but 
it  may  vary  considerably  within  normal  limits.  The  mucous  membrane 


260  THE    ABDOMEN. 

is  much  longer  than  the  other  coats,  causing  it  to  be  folded  or  corru- 
gated. 

The  greater  curvature  is  connected  with  the  transverse  colon  through 
the  medium  of  the  gastrocolic  omentum.  The  pylorus  has  a  distinct 
thickening  of  muscle,  being  here  about  3  to  4  mm.  in  thickness.  Under 
normal  conditions  the  pylorus  admits  the  index-finger  when  the  walls  of 
the  stomach  are  invaginated  into  it.  This  is  a  valuable  test  to  determine 
whether  there  is  any  obstruction  at  the  pylorus.  Such  an  obstruction 
may  be  due  to  a  benign  or  malignant  growth,  or  is  not  infrequently  due 
to  simple  muscular  hypertrophy,  or,  as  may  occasionally  be  the  case  at  the 
esophageal  end,  due  to  a  spasm  of  the  muscles.  Another  cause  of  obstruc- 
tion of  the  pylorus  is  the  cicatrix  due  to  the  healing  of  a  round  ulcer. 
To  relieve  such  an  obstruction  at  the  pylorus,  an  operation  known  as 
gastro-enterostomy  is  frequently  performed,  consisting  in  bringing  the 
jejunum  into  the  anterior  or  posterior  walls  of  the  stomach,  which  estab- 
lishes a  shorter  route  for  the  contents  of  the  stomach,  instead  of  passing 
through  the  pylorus  into  the  duodenum.  Under  these  conditions,  if  the 
pylorus  is  still  patent,  there  may  be  regurgitation  of  the  bile  and  pan- 
creatic fluid  into  the  stomach,  causing  obstinate  vomiting,  and  even  re- 
sulting fatally  (vicious  circle). 

The  stomach  is  connected  with  the  spleen  by  a  prolongation  of  the 
greater  omentum  (see  Fig.  74),  the  gastrosplenic  omentum,  which  assists 
in  anchoring  the  stomach  laterally  to  a  slight  extent. 

The  stomach  receives  a  rich  blood-supply  through  the  medium  of  the 
vessels  which  run  along  its  lesser  and  greater  curvatures.  The  left  and 
right  coronaries  run  along  the  lesser  curvature;  the  right  and  left  gastro- 
epiploic  arteries  run  along  the  greater  curvature.  The  vessels  for  the 
greater  curvature  are  derived  from  the  hepatic  artery  (right  gastro-epip- 
loic,  a  branch  of  the  gastroduodenal)  and  from  the  splenic  (left  gastro- 
epiploic).  The  hepatic  artery  gives  off  the  pyloric  artery  (arteria  gas- 
trica  dextra)  which  joins  with  the  left  coronary  or  gastric  artery 
(arteria  gastrica  sinistra),  a  branch  of  the  celiac  axis,  to  supply  the 
lesser  curvature.  These  vessels  send  off  branches  which  run  almost 
vertically  on  the  anterior  and  posterior  wall  and  anastomose  freely  with 
each  other,  so  that  the  blood-supply  of  the  stomach  does  not  come  from 
one  mesentery,  but  from  two;  that  is,  above  and  below  (Fig.  79).  Hence 
there  is  less  danger  of  gangrene  than  is  the  case  with  the  small  intestine 
and  colon,  where  the  sole  source  of  blood-supply  is  along  one  mesentery, 
the  single  mesentery  which  sustains  them. 

The  veins  empty  chiefly  into  the  portal  vein.  The  right  gastro-epip- 
loic  joins  the  superior  mesenteric  (see  Fig.  79),  the  left  gastro-epiploic 


THE   SMALL    INTESTINE.  261 

joins  the  splenic,  and  the  coronary  or  gastric  vein  and  pyloric  vein  (corre- 
sponding to  the  same  named  arteries)  also  join  the  portal  (Fig.  79).  The 
coronary  or  gastric  vein  receives  an  esophageal  branch,  so  that  in  this 
manner  there  is  communication  at  the  cardiac  end  of  the  esophagus  be- 
tween the  two  venous  systems  (Fig.  79). 

In  cases  of  cirrhosis  of  the  liver,  when  there  is  obstruction  of  the  portal 
circulation,  a  large  quantity  of  the  blood,  instead  of  returning  to  the  liver 
through  the  portal  vein,  utilizes  this  channel  between  the  two  systems  and 
returns  to  the  vena  cava  through  the  medium  of  the  esophageal  veins, 
which  become  enormously  increased  in  size  and  varicosed,  and  may 
occasionally,  as  do  varicose  veins  elsewhere,  rupture  and  give  rise  to  the 
severe  gastric  hemorrhages  occurring  in  cirrhosis  of  the  liver. 

The  walls  of  the  stomach  are  richly  supplied  with  lymphatics,  which 
pass  to  four  sets  of  glands:  (i)  those  in  the  greater  omentum  along  the 
greater  curvature;  (2)  those  in  the  lesser  omentum  in  the  lesser  cur- 
vature; (3)  those  around  the  cardiac  end  of  the  stomach  situated  on  its 
wall;  and  (4)  those  along  the  upper  border  of  the  pancreas,  to  which  the 
glands  along  the  left  half  of  the  greater  curvature  lead. 

The  lymphatics  end  sharply  at  the  pylorus,  so  that  the  transmission 
of  a  carcinoma  from  the  pylorus  to  the  duodenum  seldom  occurs.  The 
demarcation  at  the  cardiac  end  is  not  so  sharp,  hence  the  supraclavicular 
glands  may  be  enlarged  in  carcinoma  near  this  end. 

The  Small  Intestine. 

The  small  intestine  is  the  portion  of  the  alimentary  canal  which  is 
placed  between  the  stomach  and  the  beginning  of  the  large  intestine.  It 
commences  at  the  pylorus  and  ends  at  the  ileocecal  valve,  and  is  divided 
into  three  portions — the  duodenum,  jejunum,  and  ileum.  Its  entire 
length  is  eight  yards;  that  is,  twenty-four  feet,  according  to  Sappey.  The 
duodenum,  or  first  portion,  corresponds  to  a  portion  of  a  spiral;  that  is, 
it  is  ring-like. 

The  entire  duodenum  is  12  inches  (30  cm.)  long,  and  is  wider  than 
the  remainder  of  the  small  intestine  (i  J  to  2.\  inches — 4  to  6  cm.).  It  has 
a  shape  like  the  letter  C,  embracing  the  head  of  the  pancreas.  The  first 
or  horizontal  portion  begins  at  the  pylorus,  opposite  the  first  lumbar 
vertebra  (Figs.  63,  64,  and  74).  It  is  entirely  covered  by  peritoneum,  and 
is  held  in  place  by  a  continuation  of  the  lesser  omentum,  the  hepato-duo- 
denal  ligament.  It  bends  in  front  of  the  right  kidney  and  ends  at  the  neck 
of  the  gall-bladder,  at  which  point  the  second  or  vertical  portion  begins,  at 
the  side  of  the  first  lumbar  vertebra.  This  portion  is  in  direct  contact 
with  the  transverse  colon  lying  behind  it,  and  ends  at  the  right  side  of  the 


262  THE    ABDOMEN. 

third  or  fourth  lumbar  vertebra  (Fig.  62).     On  its  outer  or  right  side  it  is 
in  relation  to  the  liver;  on  its  inner,  to  the  inferior  vena  cava  and  head  of 
the  pancreas,  the  latter  overlapping  it  somewhat  in  front  (Fig.  64).     The 
relations  of  this  second  or  vertical  portion  of  the  duodenum  to  the  bile 
and  pancreatic  ducts  are  of  great  practical  value.     The  common  bile- 
duct  runs  behind  the  first  portion  of  the  duodenum,  and  then  descends 
between  the  head  of   the  pancreas  and   the  second  portion,  nearly 
as  far  as  the  middle  of  the  latter  (Fig.  63).     The  duct  is  accom- 
panied by  the  portal   vein  (lying  to  its  left),  and  the  hepatic  artery 
(lying   to   its   right)    (Fig.    79).     All    of   these   structures   lie   in   the 
hepatoduodenal  ligament,  which   may  be  made  more  prominent  by 
passing  the  finger  behind  the  ligament,  the  latter  forming  the  anterior 
wall  of  the  foramen  of  Winslow.     The  common  bile-duct  continues  be- 
hind the  vertical  portion  of  the  duodenum  (see  Fig.  63)  and  joins  with  the 
pancreatic,  opening  into  the  duodenum  obliquely  after  running  nearly  an 
inch  (2  cm.)  through  its  wall.     There  are,  therefore,  three  portions  of 
the  common  bile-duct :     The  portion  above  the  horizontal  part  of  the 
duodenum  is  called  the  supraduodenal  portion;  the  portion  behind  the 
vertical  or  second  portion  of  the  duodenum,  the  retroduodenal;  and  the 
portion  which  passes  through  the  head  of  the  pancreas  to  join  the  pan- 
creatic duct,  the  intrapancreatic  portion.     The  common  orifice  by  which 
the  pancreatic  and  common  bile-ducts  open  into  the  duodenum  is  called 
the  ampulla  of  Vater.   It  lies  about  3  J  to  4  inches  below  the  pylorus.    Not 
infrequently  an  accessory  duct  of  the  pancreas  opens  into  the  duodenum 
a  little  above  the  ampulla  of  Vater  (about  f  of  an  inch).    The  relations 
of  the  head  of  the  pancreas  to  these  ducts  and  to  this  second  or  de- 
scending portion  of  the  duodenum  are  of  the  greatest  practical  value  (Fig. 
63).     As  was  stated  above,  gall-stones  occur  not  only  in  the  gall-bladder 
and  intrahepatic  ducts,  but  also  in  the  common  duct.      When  they 
are  present  in  the  common  duct,  they  are  most  accessible  to  operative 
removal  in  the  supraduodenal  portion.     When  they  lie  at  the  junc- 
tion  of   the    common   bile-duct  and  pancreatic  duct,  they  not  only 
obstruct  the  flow  of  bile,  but   also  the  flow  of   pancreatic   fluid,  as 
Opie  has  recently  pointed  out.     Such  a  stone,  lodged  near  the  ampulla 
of  Vater,  will  permit  organisms  to  enter  the  pancreatic  duct,  causing  an 
acute  inflammation  of  the  latter  (acute  hemorrhagic  pancreatitis),  or  may 
give  rise  to  a  cyst  of  the  pancreas  (see  Pancreas).     In  a  similar  manner,  a 
stone  lying  in  the  common  duct  will  allow  organisms  to  enter  through  the 
ampulla  and  cause  the  inflammation  of  the  bile  vessels  referred  to  above 
(angiocholitis).     The  persistence  of  the  accessory  pancreatic  duct  may 
also  be  of  assistance  in  explaining  the  origin,  at  times,  of  inflammation  of 


Fig.  76. — Cross-section  of  abdomen  at  level  of  third  lumbar  vertebra.  L,  Lumbar 
vertebra.  The  nerves  of  the  cauda  equina  are  seen  projecting  from  the  spinal  canal.  P, 
Psoas  muscle.  QL,  Quadratus  lumborum.  ES,  Erector  spinae,  or  sacrospinalis.  IL, 
Iliacus  muscle,  lying  on  inner  side  of  ilium,  which  has  been  cut  through  on  the  right  side. 
A,  Ascending  colon.  D,  Descending  colon.  Note  the  fact  that  the  posterior  surfaces  of 
A  and  D  are  not  covered  by  peritoneum.  O,  Omentum.  T,  Transverse  colon,  just  be- 
fore passing  into  splenic  flexure,  seen  in  cross-section.  The  letter  T  in  the  center  of  the 
picture  is  placed  upon  the  outer  surface  of  the  transverse  colon.  H,  Hepatic  flexure  of 
colon,  upon  which  rested  that  portion  of  the  liver  and  gall-bladder  seen  in  figure  75.  i, 
Vena  cava  inferior.  2,  Aorta.  3,  Ureters.  4,  Spermatic  artery  of  right  side.  5,  Ante- 
rior layer  of  lumbar  fascia.  6,  Middle  layer  of  lumbar  fascia.  The  outer  layer  of  lumbar 
fascia  is  represented  by  the  white  line  covering  LD,  the  latissimus  dorsi,  and  ES,  erector 
spinae.  Note  the  relations  of  the  abdominal  muscles  of  the  anterior  wall  to  the  lumbar 
fascia;  also  in  the  upper  portion  of  the  picture  the  formation  of  the  sheaths  of  the  recti. 
(Compare  this  picture  with  Figs.  73,  74,  75,  77,  and  78,  in  order  to  understand  the  change 
in  relations  at  different  levels  of  abdomen.) 


263 


THE    SMALL    INTESTINE.  265 

the  pancreas.  Carcinoma  of  the  head  of  the  pancreas  through  involve- 
ment of  the  common  bile-duct  will  cause  jaundice  and  obstruction  of  the 
flow  of  pancreatic  fluid,  as  well  as  ascites  through  pressure  upon  the  por- 
tal vein  lying  immediately  to  the  left  of  it  (Fig.  79).  The  relation  of  both 
the  horizontal  and  descending  portions  of  the  duodenum  to  the  upper  and 
lower  poles  of  the  right  kidney  renders  it  possible  (see  Fig.  74)  for  ab- 
scesses of  this  kidney  to  empty  into  the  duodenum. 

The  third  or  ascending  portion  of  the  duodenum  crosses  the  spinal 
column  at  the  level  of  the  third  lumbar  vertebra,  reaching  the  left  side 
of  the  spine  opposite  the  first  or  second  lumbar  vertebra,  where  it  ends  in 
the  jejunum  (Fig.  62).  It  is  crossed  here  by  the  superior  mesenteric 
vessels  and  the  portal  vein.  The  duodenojejunal  flexure  lies  at  the  level 
of  the  first  lumbar  vertebra.  It  has  a  direction  from  behind  forward 
(see  Fig.  62).  Only  the  anterior  aspects  of  both  the  second  and  third 
portions  of  the  duodenum  are  covered  by  peritoneum.  The  posterior 
wall  is  firmly  adherent,  through  loose  areolar  tissue,  to  the  kidney, 
abdominal  aorta,  vena  cava  inferior,  lumbar  portion  of  the  diaphragm, 
and  spinal  column  (Fig.  74).  These  relations  cause  the  greater  portion 
of  the  duodenum  to  be  firmly  fixed  to  the  posterior  abdominal  wall,  and 
permit  of  only  slight  movement,  so  that  if  a  rupture  of  this  portion  of  the 
intestine  occurs,  it  is  always  at  the  junction  of  the  fixed  and  movable 
portions — the  duodenojejunal  flexure. 

The  remainder  of  the  small  intestine  is  wider  above — 25  to  35  mm.  (i 
to  i  J  inches) — than  below, — 20  to  25  mm.  (j  to  i  inch).  The  coils  of  the 
jejunum  occupy  in  general  the  upper  and  left  portion,  and  the  ileum,  the 
lower  and  right  portions  of  the  area  in  which  the  small  intestines  lie.  In 
general,  the  jejunum  and  ileum  are  separated  from  the  abdominal  wall 
by  the  omentum  (Fig.  76),  and  when  this  is  retracted,  they  are  in  direct 
contact  with  the  parietal  peritoneum.  They  lie  chiefly  in  the  umbilical 
and  hypogastric  regions,  but  overlap  the  colon  (ascending  and  descend- 
ing) in  the  lumbar  and  iliac  regions  of  each  side.  They  lie,  as  it  were,  in  a 
frame  formed  by  the  ascending,  transverse,  and  descending  colon.  Their 
mesentery  varies  in  length,  being  longest  about  20  to  25  cm.  (8  to  10 
inches)  above  the  cecum,  and  again  becoming  shorter  15  cm.  (6  inches) 
above  the  ileocecal  valve,  so  that  the  middle  and  a  little  below  the  middle 
portion  of  the  jejunum  and  ileum  have  the  most  mobility,  and  hence  are 
frequently  found  in  inguinal  and  femoral  herniae.  Where  the  duodenum 
passes  into  the  jejunum,  there  is  a  blind  pouch  or  sac — the  fossa  duo- 
deno-jejunalis.  In  rare  cases  it  may  contain  a  coil  of  small  intestine, 
giving  rise  to  a  retroperitoneal  hernia.  The  mesentery  which  suspends 
the  jejunum  and  ileum  has  its  line  of  attachment  from  the  left  side  of  the 
17 


266  THE    ABDOMEN. 

first  lumbar  vertebra  in  an  oblique  direction  downward  and  to  the  right, 
as  far  as  the  front  of  the  right  sacro-iliac  joint.  To  find  the  jejunum,  the 
omentum  and  transverse  colon  should  be  lifted  up,  the  small  intestines 
pushed  to  the  right,  when  it  can  be  found  immediately  below  the 
pancreas.  The  arterial  supply  of  the  jejunum  and  ileum  is  derived 
from  the  superior  mesenteric  (Fig.  79).  In  atheromatous  conditions 
this  artery  occasionally  becomes  the  seat  of  an  embolus,  or  is  oc- 
cluded by  a  thrombus,  resulting  in  severe  symptoms  resembling  those 
of  intestinal  obstruction,  bloody  stools,  vomiting,  severe  pain  in  the  ab- 
domen, etc.  The  veins  empty  into  the  superior  mesenteric  vein,  a 
branch  of  the  portal  '(Fig.  79).  A  thrombosis  of  these  veins  causes 
gangrene  of  the  loop  of  bowel  which  they  supply,  and  a  septic  phlebitis 
may  extend  upward  to  the  liver,  and  cause  an  abscess.  The  lymphatics 
lie  in  the  submucous  and  muscular  coats,  as  in  the  stomach,  and 
empty  into  the  mesenteric  glands,  about  two  hundred  in  number, 
which  empty  into  the  thoracic  duct.  These  glands  become  enlarged 
quite  early  in  all  infectious  processes  of  the  intestine  (typhoid,  dysentery, 
appendicitis),  and  in  tuberculosis  may  become  so  large  as  to  resemble 
tumors.  After  attacks  of  appendicitis  they  are  apt  to  become  greatly  en- 
larged in  that  portion  of  the  mesentery  and  mesocolon  close  to  the  cecum. 

The  Large  Intestine. 

The  large  intestine  is  about  nine  feet  in  length;  it  begins  at  the  cecum, 
which  lies  close  behind  the  anterior  abdominal  wall  in  the  right  iliac  re- 
gion (Figs.  6 1  and  77).  From  the  lower  back  portion  of  the  cecum  is  the 
most  frequent  point  of  origin  of  the  appendix ;  since  the  position  of  the 
cecum  varies  to  some  extent,  so  does  that  of  the  appendix.  The  most 
typical  position  is  for  it  to  hang  downward  over  the  pelvic  brim  (Fig.  61), 
although  it  may  point  toward  the  kidney,  liver,  bladder,  or  even  lie  extra  - 
peritoneally  behind  the  cecum.  The  average  length  of  the  appendix  is 
5  to  8  cm.  This  is  also  subject  to  variation.  The  appendix  gradually 
becomes  obliterated  toward  old  age.  The  appendix  is  suspended  by 
a  prolongation  of  the  mesocolon  known  as  the  mesenteriolum,  in  which 
are  several  arteries  and  veins,  as  well  as  lymphatics.  The  cecum  and 
appendix  lie  upon  the  peritoneum  of  the  right  iliac  fossa  (see  Fig.  77),  in 
close  relation  to  the  iliac  vessels  at  the  pelvic  brim.  The  appendix  being 
entirely  covered  by  peritoneum,  an  inflammation  with  perforation  of  its 
coats  will  cause  the  contents  to  be  extravasated  directly  into  the  general 
peritoneal  cavity,  unless  the  process  is  walled  off  through  adhesions  of  the 
omentum,  adjacent  small  intestines,  colon,  and  parietal  peritoneum. 

In  figure  81  are  shown  the  places  in  the  abdomen  in  which  abscesses 


Fig-  77- — Cross-section  of  pelvis  at  level  of  sacro-iliac  joints.  S,  Sacrum.  I,  Ilium. 
SC,  Iliac  colon  (sigmoid  flexure).  C,  Cecum,  and  beginning  of  ascending  colon,  i, 
Placed  to  inner  side  of  each  sacro-iliac  joint.  2,  Ureters.  3,  Mesosigmoid,  showing  great 
length  of  latter.  4,  Pelvic  colon  not  cut,  seen  from  above.  5,  Omentum.  6,  External 
iliac  artery.  7,  External  iliac  vein.  8,  Iliopsoas  muscle.  The  white  dot  above  it  is  the 
anterior  crural  nerve.  9,  10,  and  n,  Gluteal  muscles. 


267 


Fig.  78. — Cross-section  of  female  pelvis  at  level  of  lower  portion  of  coccyx.  C, 
Coccyx.  G,  Gluteal  muscles.  B,  Obturator  internus.  I,  Ischium  and  descending 
ramus  of  pubis.  F,  Head  and  neck  of  femur.  P,  Pectineus  muscle.  R,  Rectum,  seen  in 
cross-section.  One  of  Houston's  valves  is  seen  on  the  right  edge.  V,  Vagina,  the  light 
spot  at  the  anterior  margin  represents  the  external  orifice.  U,  Cross-section  of  urethra, 
i,  External  iliac  vein  lying  upon  the  pectineus  muscle.  2,  External  iliac  artery.  3, 
Anterior  crural  nerve.  4,  Parietal  layer  of  pelvic  fascia.  5,  Inferior  vesical  artery.  6, 
7,  8,  and  9  Muscles  on  anterior  aspect  of  thigh  (iliopsoas,  pectineus,  and  sartorius). 


269 


THE    LARGE    INTESTINE.  271 

most  frequently  occur,  either  directly  or  indirectly,  as  the  result  of  ap- 
pendicitis. The  most  frequent  point  is  in  the  immediate  neighborhood 
of  the  ileocecal  region,  about  50  per  cent. ;  the  next  most  frequent  point 
is  close  to  the  hepatic  flexure  of  the  colon;  then  the  abscesses  occurring 
around  the  pelvic  organs,  especially  between  the  rectum  and  vagina, 
where  they  can  be  drained  through  an  incision  in  the  lateral  wall  of  the 
rectum.  The  proximity  of  the  appendix  to  the  Fallopian  tube  ren- 
ders the  transmission  of  infection  from  one  to  the  other  easy. 
The  relation  of  such  intraperitoneal  abscesses  to  the  adjacent  hol- 
low viscera  will  explain  the  frequency  with  which  they  perforate  into 
the  small  and  large  intestines,  bladder,  and  rectum.  The  abscesses 
not  infrequently  become  extraperitoneal  through  adhesions  to  the  ab- 
dominal parietes,  burrowing  down  even  under  the  pelvic  fascia,  so  as 
to  simulate  ischiorectal  abscesses.  The  posterior  portion  of  the  cecum 
is  generally  not  covered  by  peritoneum.  At  times  the  cecum  may  have 
such  a  long  mesentery,  however,  that  it  enters  a  hernial  sac,  giving  rise 
to  the  form  known  as  cecal  hernia.  Beneath  the  cecum  there  is  a  blind 
pocket  or  pouch  of  peritoneum  known  as  the  fossa  subcaecalis,  which  may 
also  be  the  seat  of  a  hernia.  The  ascending  colon  ascends  between  the 
iliacus  and  psoas,  close  to  the  posterior  wall  of  the  abdomen,  until  it 
reaches  the  lower  surface  of  the  liver,  where  it  turns  into  the  transverse 
colon  (hepatic  flexure)  (Fig.  42).  It  lies  along  the  outer  edge  of  the 
quadratus,  and  comes  in  close  contact  with  the  right  kidney  (Figs.  62 
and  76).  Only  its  external  and  anterior  surfaces  are  free  and  covered  by 
peritoneum  (see  Fig.  76).  Its  internal  and  posterior  surfaces  are  closely 
adherent  to  the  underlying  structures.  The  transverse  colon  passes 
toward  the  anterior  wall  of  the  abdomen  again,  across  the  upper  border 
of  the  umbilical  region,  passing  again  toward  the  posterior  wall  of  the 
abdomen,  when  it  reaches  the  lower  end  of  the  spleen  (Figs.  42,  62,  and 
76).  It  is  suspended  from  the  stomach  by  the  transverse  mesocolon,  and 
hanging  down  from  its  lower  edge  is  the  great  omentum.  The  lengths  of 
the  transverse  colon  and  of  its  mesentery  vary  greatly,  so  that  the  loop 
may  extend  into  the  pelvis.  At  the  splenic  flexure  the  colon  is  fixed  to  the 
spleen  by  a  continuation  of  the  greater  omentum — the  phrenocolic  liga- 
ment. At  the  splenic  flexure  the  turn  of  the  colon  is  so  abrupt  that  the 
two  portions  may  lie  parallel  to  each  other  (Fig.  76).  The  descending 
colon  lies  also  close  to  the  posterior  abdominal  wall,  coming  in  close  con- 
tact with  the  left  kidney,  the  spleen,  and  the  pancreas  (see  Figs.  70,  76, 
and  77)  until  it  passes  over,  at  about  the  crest  of  the  ilium,  into  the  iliac 
colon  or  sigmoid  flexure.  The  descending  colon,  like  the  ascending,  is 
covered  by  peritoneum  only  on  its  external  and  anterior  aspects  (see  Figs. 


272  THE    ABDOMEN. 

76  and  77)  and  has  a  very  short  mesentery,  being  adherent  along  its 
posterior  aspect  to  the  kidney  and  retroperitoneal  connective  tissue. 
Abscesses  arising  from  the  posterior  wall  of  the  ascending  or  descending 
colon  penetrate  into  the  extraperitoneal  tissue.  The  iliac  and  pelvic 
colons  (sigmoid  flexure  in  older  terminology)  extend  from- the  left  upper 
crest  of  the  ilium  to  the  middle  of  the  sacrum,  the  pelvic  beginning  at 
the  brim  of  the  pelvis.  It  has  a  very  long  mesentery  (Fig.  77),  and  is 
most  frequently  used  to  form  an  artificial  anus  in  the  left  iliac  region. 
On  account  of  its  long  mesentery,  it  readily  becomes  twisted,  giving  rise 
to  volvulus,  a  form  of  intestinal  obstruction. 

The  rectum  begins  about  the  middle  of  the  sacrum,  and  will  be  de- 
scribed with  the  pelvis. 

At  the  junction  of  the  ileum  and  cecum  there  are  two  folds  of  mucous 
membrane  (ileocecal  valve)  which  prevent  regurgitation  from  the  cecum 
to  the  ileum.  The  stomach  contents  remain  acid  in  the  lower  portion  of 
the  duodenum,  where  they  are  mixed  with  bile  and  pancreatic  fluid. 
This  decreases  the  acid  reaction,  but  the  latter  remains  until  the  contents 
reach  the  colon.  At  the  ileocecal  valve  the  intestinal  contents  are  thick, 
acid  in  reaction,  light  yellow  to  green  in  color.  The  majority  of  the 
absorption  takes  place  in  the  ileum  and  colon.  The  function  of  the 
colon  is  chiefly  to  absorb  the  water;  that  is,  to  inspissate  the  refuse 
bowel  contents.  The  contents  of  the  stomach  require  three  to 
six  hours  to  travel  from  the  stomach  to  the  ileocecal  valve,  and 
from  this  point  to  the  rectum  about  twelve  hours.  From  the 
duodenum  downward  the  number  of  micro-organisms  in  the  alimen- 
tary canal  increases,  becoming  greatest  in  the  large  intestine,  where 
putrefaction  begins.  The  amount  of  indican  in  the  urine  is  an  index 
of  the  amount  of  putrefaction  in  the  colon.  In  addition  to  the  water- 
absorption  properties  of  the  colon,  the  rectum  and  a  portion  of  the 
pelvic  colon  have  the  power  of  absorbing  peptones,  sugars,  and  emul- 
sified fats.  This  fact  is  utilized  in  rectal  feeding,  it  being  possible 
for  the  system  to  be  nourished  for  a  number  of  days  or  weeks 
through  the  capacity  of  this  portion  of  the  bowel  to  absorb  nutriment. 
In  thin  persons  the  ascending  and  descending  colon  may  be  felt  deeply 
situated  in  the  abdominal  cavity  as  firm  cords,  at  times  resembling 
tumors.  The  ascending,  transverse,  and  a  portion  of  the  descending  colon 
are  nourished  by  the  colic  branches  of  the  superior  mesenteric  artery 
(Fig.  79).  Their  blood  returns  through  the  colic  veins  and  superior 
mesenteric  to  the  portal  veins,  and  pylcphlebitis  along  this  avenue  gives 
rise  to  abscesses  of  the  liver  following  dysenteric  ulcerations  of  the  large 
intestine. 


Cystic 
artery 


Esophageal  venous  anastomosis 


Splenic  artery 
and  vein 


Spleen 


Left  gastro-epi- 
ploic  artery 


Fig.  79. — Blood-supply  of  abdominal  viscera  (modified  Joessl).  B,  Common  bile- 
duct.  The  arrow  upon  its  right  (to  left  in  body)  shows  the  course  of  the  blood  flowing 
back  from  the  right  coronary  vein  into  the  portal  vein.  P,  Portal  vein.  H,  Hepatic 
artery.  C,  Celiac  axis.  The  white  arrow  seen  between  H  and  C  indicates  the  blood  re- 
turning from  the  left  coronary  into  the  splenic  vein.  M,  Superior  mesenteric  artery. 
Just  below  the  letter  the  superior  mesenteric  is  given  off,  which  supplies  the  ascending 
colon,  transverse  colon  through  the  colic  arteries  (R),  and  all  of  the  small  intestine  except 
the  duodenum  through  the  mesenteric  vessels  (S).  A,  Aorta,  between  inferior  and  supe- 
rior mesenteric  vessels.  IF,  Inferior  mesenteric  artery,  supplying  the  descending  iliac 
pelvic  colon  and  greater  portion  of  the  rectum.  Accompanying  R,  S,  and  L  can  be  seen 
the  corresponding  veins  (splenic,  superior  and  inferior  mesenteric)  which  return  the  blood 
(along  the  paths  indicated  by  the  black  arrows  above  the  lesser  curvature  of  the  stomach) 
into  P,  the  portal  vein.  CA,  Right  and  left  coronary  arteries.  D,  Gastroduodenal 
artery,  which  divides  into  the  superior  pancreaticoduodenal  and  the  right  gastro-epiploic 
artery.  GE,  Gastro-epiploic  arteries  and  veins. 


273 


THE    SPLEEN.  275 

When  an  artificial  anus  is  established,  the  point  of  preference  is  usu- 
ally the  iliac  colon.  At  times,  in  cases  of  intestinal  obstruction,  it  be- 
comes necessary  to  establish  the  opening  at  a  higher  point.  Care  should 
be  taken,  however,  to  open  the  bowel  at  as  low  a  point  as  possible, 
otherwise  the  patient  will  starve  through  lack  of  absorption,  especially  if 
the  lower  portion  of  the  ileum  is  involved.  The  large  intestine  can  be 
readily  distinguished  from  the  small  intestine  by  its  longitudinal  mus- 
cular bands,  and  the  haustra  or  bulging  portions  of  the  intestine  between 
these  bands  (Fig.  71).  At  the  end  of  the  anterior  longitudinal  band 
of  the  ascending  colon  and  cecum  the  appendix  is  usually  found.  The 
blood  of  the  lower  portion  of  the  descending,  iliac,  and  pelvic  colon  is 
returned  by  the  inferior  mesenteric  vein  (Fig.  79).  The  nerves  are  de- 
rived from  the  inferior  and  superior  mesenteric  plexuses  (Fig.  91). 

On  account  of  the  close  proximity  of  the  small  intestines  to  the  ante- 
rior abdominal  wall,  they  are  not  infrequently  injured  in  contusions  of  the 
viscera  without  external  wounds.  These  usually  affect  the  ileum,  or  the 
jejunum  close  to  the  duodenojejunal  flexure,  where  the  intestine  is  fixed. 
In  the  majority  of  instances  the  intestine  is  perforated  through  direct 
action  of  the  force,  being  caught  between  the  spinal  column,  as  will  be 
readily  understood  from  a  reference  to  figure  77,  and  the  abdominal  wall, 
by  a  horse-kick,  fall  upon  a  blunt  object,  etc.  At  the  lower  portion  of  the 
ileum  are  situated  the  solitary  follicles  and  Peyer's  patches,  so  that 
typhoid  perforations  are  most  frequently  found  close  to  the  ileocecal 
valve. 

In  the  above  description,  the  suggestion  made  by  Jonnesco  has  been 
followed  in  calling  that  portion  of  the  colon  which  lies  in  the  iliac  fossa 
the  iliac  colon,  and  that  portion  which  lies  in  the  pelvis  the  pelvic  colon. 
The  iliac  colon  includes  the  portion  of  the  sigmoid  flexure  which  extends 
from  the  crest  of  the  ilium  to  the  brim  of  the  pelvis.  The  pelvic  colon 
embraces  the  remainder  of  the  sigmoid  colon  and  the  first  part  of  the 
rectum  of  the  old  descriptions.  This  has  a  long  mesentery  and  forms 
a  large  loop  lying  in  the  pelvic  cavity.  It  ends  at  the  third  sacral  ver- 
tebra in  the  rectum  proper.  The  latter  will  be  described  in  its  topo- 
graphic relations  to  the  other  viscera  of  the  male  and  female  pelvis. 
(See  below.) 

The  Spleen. 

The  spleen  lies  deeply  in  the  left  hypochondriac  region,  between  the 
stomach  and  the  diaphragm.  Its  outer  or  diaphragmatic  surface  rests 
upon  the  back  part  of  the  diaphragm,  being  separated  from  the  chest- 
wall  by  the  diaphragm  and  the  costo-diaphragmatic  reflection  of  the 


276  THE    ABDOMEN. 

pleura  (sec  Fig.  43)  as  well  as  the  lower  margin  of  the  left  lower  lobe  of 
the  lung.  Its  upper  end  reaches  the  tenth  dorsal  vertebra;  its  anterior 
border  seldom  reaches  beyond  the  costo-clavicular  line  (a  line  drawn 
from  the  sterno-clavicular  joint  to  the  tip  of  the  tenth  rib),  though 
occasionally  it  extends  to  the  mid-axillary  line.  Its  inner  surface  is  in 
relation  to  the  fundus  of  the  stomach,  and  at  this  point  the  hilus  of  the 
organ  is  situated,  where  the  splenic  artery,  a  branch  of  the  celiac  axis 
(see  Figs.  64  and  79),  enters.  The  splenic  vein  passes  parallel  with  the 
artery  to  enter  the  portal  (see  Fig.  79)  vein. 

In  addition  to  being  in  contact  with  the  stomach,  the  spleen  is  also  in 
close  relation,  by  its  inner  surface,  to  the  kidney  and  splenic  flexure  of  the 
colon.  The  anterior  border  points  downward  and  is  usually  notched,  so 
that  when  the  spleen  is  enlarged  and  projects  below  the  left  costal  arch, 
this  notched  border  is  a  means  of  identification  of  the  organ. 

The  upper  portion  of  the  spleen  with  the  fundus  of  the  stomach  and 
left  lobe  of  the  liver  (see  Figs.  61  and  62)  occupy  the  left  subphrenic  space, 
so  that  abscesses  of  the  spleen  often  rupture  into  this  space,  or,  on  ac- 
count of  the  relation  of  the  spleen  to  the  stomach  and  splenic  flexure  of 
the  colon,  the  abscesses  may  rupture  into  either  of  these  viscera,  or  into 
the  left  pleural  cavity.  The  spleen  is  entirely  surrounded  by  peritoneum. 
It  is  rather  imperfectly  held  in  place,  its  best  means  of  fixation  being  a 
ligament  by  which  it  is  attached  to  the  diaphragm — the  phrenosplenic. 
It  is  also  attached  to  the  stomach  by  the  gastrosplenic  omentum  and  to 
the  colon  by  the  phrenocolic  ligament.  The  spleen  rests  upon  the  latter. 

The  long  axis  of  the  spleen  corresponds  to  the  course  of  the  tenth  rib, 
and  upon  the  surface  of  the  bony  thorax  it  extends  from  the  ninth  to  the 
eleventh  ribs  and  from  the  above-mentioned  costo-clavicular  or  mid- 
axillary  line  backward  to  the  spine  (Fig.  62). 

The  spleen  moves  with  respiration,  but  its  respiratory  mobility  is  less 
than  that  of  the  liver.  Fluid  in  the  left  pleural  cavity  pushes  the  spleen 
downward.  On  account  of  the  lax  fixation  of  the  spleen,  it  may  migrate 
to  almost  any  portion  of  the  abdominal  cavity,  and  cases  have  been 
reported  where  enlargements  in  the  right  iliac  region,  and  even  in  the 
pelvis,  have  been  found  to  be  due  to  a  wandering  spleen.  In  order  to  fix 
the  spleen  (splenopexy),  an  incision  is  made  along  the  left  border  of  the 
left  rectus,  and  it  is  attached  .as  close  as  possible  along  the  line  of  the 
phrenosplenic  ligament,  or  at  times  it  is  placed  in  a  slit  in  the  abdominal 
muscles. 

Abscesses  of  the  spleen,  of  embolic  origin,  occur  in  pyemia.  The 
spleen  is  at  times  enormously  enlarged.  During  malaria,  in  one  of  the 
forms  of  leukemia,  and  in  tumors  of  the  spleen  it  may  be  so  large  as  to 


THE    PANCREAS.  277 

occupy  the  entire  left  half  of  the  abdominal  cavity.     It  can  usually  be 
recognized  by  its  crenated  or  notched  edge. 

A  large  number  of  cases  of  subcutaneous  rupture  of  the  spleen  have 
been  reported.  These  have  occurred  through  a  crushing  force  in  which 
the  spleen  was  caught  between  the  force  and  the  spinal  column  on 
account  of  the  yielding  character  of  the  lower  ribs. 

The  Pancreas. 

The  pancreas  is  an  elongated,  glandular  mass  lying  behind  the  stom- 
ach at  the  level  of  the  first  and  second  lumbar  vertebrae.  In  thin  sub- 
jects, especially  in  old  age,  it  may  be  felt  through  the  anterior  abdominal 
wall  as  a  horizontal  thickening  above  the  umbilicus,  simulating  a  neo- 
plasm. 

Its  head  is  surrounded  by  the  vertical  and  ascending  portions  of  the 
duodenum,  the  common  bile-duct  lying  between  the  bowel  and  the  head 
of  the  pancreas  (see  Figs.  63,  64,  and  80) ;  behind  it  lie  the  vena  cava  and 
aorta  (see  Fig.  79).  The  neck  joins  the  head  with  the  body.  On  its 
posterior  surface  lies  the  portal  vein.  The  body  and  its  termination, 
called  the  tail,  are  10  to  12  cm.  (4  to  5  inches)  long.  Its  anterior  surface 
is  covered  (see  Fig.  72)  by  the  peritoneum  of  the  lesser  omental  cavity 
and  is  in  relation  with  the  posterior  wall  of  the  stomach.  The  inferior 
surface  rests  upon  the  duodeno-jejunal  flexure  and  transverse  colon,  just 
before  passing  into  the  splenic  flexure  (Fig.  74). 

Its  posterior  surface  is  firmly  adherent  to  the  aorta,  left  renal  vessels, 
and  left  kidney.  The  splenic  artery  runs  along  this  surface  close  to  its 
upper  edge.  The  organ  normally  possesses  two  ducts,  which  may  open 
separately  into  the  duodenum.  The  main  duct  joins  near  the  head  with 
the  common  bile-duct,  and  opens  with  it  into  the  duodenum  (Fig.  80), 
the  accessory  duct  opens  a  little  higher  up. 

Calculi  form  in  these  ducts,  giving  rise  to  colic  resembling  that  of  gall- 
stones, with  fat  diarrhea  and  diabetes.  The  effect  of  a  carcinoma  of  the 
head  has  been  described  under  the  duodenum.  It  has  been  found  that 
the  escape  of  the  secretion  of  the  pancreas  into  the  retroperitoneal  con- 
nective tissue  or  upon  the  surface  of  the  peritoneum  will  cause  a  fat 
necrosis.  Cysts  of  the  pancreas  not  infrequently  develop  after  abdo- 
minal injuries,  or  even  spontaneously,  as  a  result  of  inflammations  of  the 
pancreas.  They  either  push  forward  toward  the  anterior  abdominal  wall 
in  the  lesser  omental  cavity  between  the  stomach  and  liver,  or  between  the 
stomach  and  transverse  colon.  A  less  frequent  development  is  between 
the  layers  of  the  transverse  mesocolon. 

The  functions  of  the  pancreas  are  that  it  has  some  relation  to  diabetes, 


278  THE    ABDOMEN. 

total  extirpation  of  the  organ  causing  genuine  glycosuria.  Even  tumors 
like  carcinoma  will  cause  diabetes.  It  also  assists  in  digesting  fats  and 
albumins,  so  that  if,  in  addition  to  sugar  in  the  urine,  there  is  evidence  of 
free  fat  in  the  feces  and  of  imperfect  digestion  of  albumins,  there  should 
be  a  strong  suspicion  of  pancreatic  disease. 

The  Kidneys. 

The  kidneys  lie  on  either  side  of  the  spinal  column,  extending  from 
the  upper  border  of  the  twelfth  dorsal  vertebra  to  the  lower  border  of  the 
second  lumbar  (Figs.  71  and  87),  or  even  to  the  middle  of  the  third;  that 
is,  externally  they  extend  from  the  spine  of  the  eleventh  dorsal  to  that 
of  the  second  lumbar  vertebra  (Figs.  42  and  62).  The  right  kidney  is 
generally  about  one  finger's-breadth  lower  than  the  left.  They  usually 
lie  lateral  to  the  transverse  processes,  but  they  may  approach  the  bodies 
of  the  vertebrae,  and  even  lie  upon  them.  Their  posterior  surface  rests 
upon  the  quadratus  lumborum  (see  Figs.  74  and  75)  at  its  inner  edge,  the 
outer  edge  of  the  kidney  resting  upon  the  transversalis  muscle,  being 
separated  from  the  skin  by  the  latissimus  dorsi  and  lumbodorsal  fascia 
of  the  transversalis  muscle. 

The  relation  of  the  upper  poles  of  both  kidneys  is  of  great  practical 
value.  Under  normal  conditions  the  reflection  of  the  pleura  corresponds 
to  a  line  drawn  from  the  body  of  the  twelfth  dorsal  vertebra  and  crossing 
the  twelfth  rib  at  about  its  middle  (Fig.  42).  According  to  Luschka,  it  is 
still  lower,  touching  the  tip  of  the  twelfth  rib.  The  twelfth  rib  is  oc- 
casionally very  short,  or  absent.  It  is  always  best,  before  performing 
any  operation  upon  the  kidney  with  a  view  to  removal  of  the  same,  to 
count  the  free  edges  of  the  last  two  ribs  in  order  to  determine  if  the 
twelfth  is  absent,  on  account  of  the  danger  of  opening  the  pleural  cavities. 

In  this  manner  the  upper  pole  of  the  right  kidney,  as  well  as  the 
suprarenal  capsule,  which  lies  upon  it  at  this  point,  are  close  to  the  com- 
plementary sinus  of  the  pleura.  Hence  abscesses  of  the  kidney  may 
perforate  into  the  pleural  cavity  and  cause  an  empyema. 

Both  kidneys  are  inclosed  in  a  fibrous  capsule,  which  is  thin,  and 
may  be  readily  stripped  from  the  parenchyma.  It  has  been  proposed  of 
late  to  remove  this  capsule  in  order  to  relieve  the  congestion  due  to  acute 
and  chronic  inflammations  of  the  kidney. 

Adherent  to  the  fibrous  capsule  by  numerous  frail  bundles  of  con- 
nective tissue  is  the  fatty  capsule.  It  is  not  present,  generally,  up  to  the 
tenth  year,  and  disappears  with  general  emaciation. 

A  third  capsule  has  been  described  by  Gerota,  called  the  renal  or 
perinephric  fascia,  lying  outside  of  the  fatty  capsule.  Its  anterior  layer 


Fig.  80. — Topographical  relations  of  liver,  b'le-passages,  duodenum,  pancreas,  and 
kidneys.  S.,  Stomach,  shown  in  dotted  outline,  pulled  upward.  L,  Cut  edge  of  right  lobe 
of  liver.  P.V.,  Portal  vein.  As.V.,  Ascending  vena  cava.  D.C.,  Common  duct,  shown 
in  dotted  outline,  as  it  passes  through  the  wall  of  the  duodenum.  G.,  Gall-bladder,  whose 
cystic  duct  joins  with  the  hepatic  duct  to  form  the  common  duct  lying  to  the  right  of  the 
portal  vein.  Du.,  Duodenum.  Sp.,  Spleen.  R.K.,  Right  kidney.  L.K.,  Left  kidney. 
Coe.,  Celiac  axis.  A.,  Aorta.  C.O.,  Cardiac  orifice  of  stomach.  Di.,  Diaphragm.  P, 
Pancreas.  Py.,  Pyloric  end  of  stomach.  V.,  Duct  of  Wirsung  joining  with  common  bile- 
duct.  A.W.,  Accessory  duct  of  Wirsung. 


279 


Fig.  81. — Most  frequent  location  of  post-appendiceal  abscesses.  AP,  Appendix.  M, 
McBurney's  line.  A,  Ascending  colon.  T,  Transverse  colon.  L,  Liver.  St,  Stomach. 
Sp,  Spleen.  RSP,  Right  subphrenic  abscess.  LSP,  Left  subphrenic  abscess.  PC, 
Pelvic  colon.  R,  Rectum. 


281 


THE    KIDNEYS.  283 

passes  across  the  front  of  the  kidney  and  meets  the  same  layer  of  the 
opposite  kidney.  The  posterior  layer  is  attached  to  the  periosteum  of 
the  vertebrae.  This  fascia  is  adherent  anteriorly  to  the  peritoneum. 

The  renal  vessels  and  ureter  enter  the  kidney  at  the  pelvis,  and  are  its 
chief  support,  the  various  capsules  being  uncertain  and  insecure  sup- 
ports. 

A  mobility  of  an  inch  of  either  kidney  is  not  considered  abnormal  in 
an  inward,  upward,  or  downward  direction,  but  the  kidney  is  prevented 
from  moving  outward  by  a  normal  arrangement  of  the  perinephric  fascia. 
The  degrees  of  abnormal  mobility  (Morris)  are : 

1 .  When  the  kidney  moves  up  and  down  so  that  the  lower  half  comes 
between  the  two  fingers  during  inspiration. 

2.  When  the  greater  part,  or  even  the  whole,  of  the  kidney  can  be 
grasped  during  a  deep  inspiration,  but  ascends  again  during  expiration. 

3.  When  the  whole  kidney  descends  below  the  examiner's  fingers  and 
can  be  retained  below  them  after  the  patient  makes  a  full  expiration. 

The  kidneys  lie  rather  obliquely  in  the  abdomen ;  the  outer  border  is 
directed  somewhat  upward  and  backward,  the  inner,  downward  and  for- 
ward (Fig.  71).  The  hilum  of  the  left  kidney  is  two  inches  from  the 
aorta;  the  hilum  of  the  right  is  about  if  inches  from  the  vena  cava. 
Both  kidneys  lie  behind  the  peritoneum,  being  separated  from  it  by  a 
considerable  amount  of  loose,  areolar,  subperitoneal  tissue  (Figs.  71  and 
89).  On  the  right  side  the  lower  third  is  free,  not  being  covered  by 
peritoneum.  The  right  kidney  is  in  relation  on  its  anterior  surface,  in  its 
upper  two-thirds,  with  the  liver;  its  lower  third  with  the  hepatic  flexure 
of  the  colon,  and  its  inner  edge  is  adherent  to  the  duodenum.  It  is  very 
firmly  connected  with  the  colon,  so  that  perinephric  abscesses  not  infre- 
quently rupture  into  this.  At  its  upper  pole  lies  the  suprarenal  capsule 
between  the  kidney  and  liver.  The  left  kidney  is  separated  from  the 
fundus  of  the  stomach  by  the  splenic  artery  (upper  third) ;  its  middle  third 
is  in  contact  with  the  pancreas;  its  lower  third  is  covered  by  parietal 
peritoneum  (Fig.  62).  The  external  border  of  this  kidney  is  in  contact, 
in  the  upper  two-thirds  of  its  extent,  with  the  spleen,  and  in  the  lower 
third  with  the  descending  colon. 

The  suprarenal  capsule  is  loosely  connected  with  each  kidney  in 
the  upper  pole,  being  contained  within  the  layers  of  the  perinephric 
fascia.  At  the  pelvis  of  the  kidney  each  renal  artery  divides  into  three 
chief  branches,  which  sink  into  the  sinus  behind  the  corresponding 
branches  of  the  renal  vein.  The  renal  vein  is  a  short,  wide  vessel  and 
forms  one  of  the  principal  supports  of  the  kidney;  its  primary  branches, 

four  or  five  in  number,  issue  from  the  hilum  in  front  of  the  branches 
18 


284  THE   ABDOMEN. 

of  the  artery  until  it  joins  the  vena  cava.  The  left  vein  is  longer  than 
the  right  (see  Figs.  70  and  87).  The  left  renal  vein  is  joined  by  the 
left  spermatic  vein.  The  renal  artery  above  it  at  the  hilum  gives  one 
or  two  small  branches  to  the  suprarenal  body  and  to  the  ureter.  The 
renal  vein  also  receives  branches  after  leaving  the  hilum. 

The  kidney  may  be  congenitally  displaced,  being  usually  found  in 
the  iliac  fossa  at  the  entrance  of  the  true  pelvis,  or  at  the  promontory, 
or  even  further  in  the  pelvis,  even  in  front  of  the  rectum.  The  author 
observed  a  case  at  autopsy  in  which  the  latter  position  was  a  cause  of 
difficult  labor.  If  one  of  the  kidneys  is  missing,  the  other  is  usually 
in  its  normal  position. 

The  Ureter. 

The  ureter  begins  at  the  pelvis  of  the  kidney,  and  at  this  point 
renal  calculi  are  apt  to  lodge,  although  they  may  be  so  large  as  to  form 
a  complete  cast  of  the  kidney,  extending  up  into  the  calyces.  At  the 
point  where  the  pelvis  passes  over  into  the  ureter,  there  is  a  sudden 
narrowing  of  the  caliber,  and  strictures  of  the  ureter  are  not  infre- 
quently situated  here. 

The  ureter  descends  from  a  point  just  above  the  lower  extremity  of 
the  kidney  (see  Fig.  59)  (lying  upon  the  psoas  muscle  [see  Figs.  76,  77, 
and  87]  and  behind  the  peritoneum)  to  the  brim  of  the  pelvis.  At 
this  point  it  crosses  the  lower  end  of  the  common  iliac  artery,  and  turns 
abruptly  backward  and  outward  on  the  side  wall  of  the  pelvis  to  a 
point  about  an  inch  in  front  of  the  spine  of  the  ischium;  thence  it  passes 
forward  and  inward  on  the  upper  surface  of  the  levator  ani  to  its  termina- 
tion at  the  base  of  the  bladder.  That  portion  of  the  ureter  which  lies 
above  the  brim  of  the  pelvis  is  called  the  abdominal  portion,  and  is 
about  five  inches  in  length.  The  portion  between  the  brim  of  the 
pelvis  and  the  bladder  is  called  the  pelvic  portion.  Its  relation  to  the 
male  and  female  genitalia  will  be  described  under  "The  Pelvis." 

The  average  length  of  the  ureter  is  about  30  cm.  (12  inches),  the 
left  being  slightly  longer  than  the  right  on  account  of  the  higher  position 
of  the  left  kidney.  The  diameter  of  the  ureter  is  not  uniform;  it  pre- 
sents three  contractions  and  two  intermediate  dilatations.  The  first 
contraction  is  the  narrow  portion  of  the  ureter  (Fig.  70),  and  is  situated 
about  7  cm.  (2j  inches)  below  the  hilum  of  the  kidney.  The  second 
contraction,  called  the  inferior  isthmus,  is  at  the  angular  bend  at  the 
foot  of  the  pelvis,  and  the  third  contraction  is  at  its  termination  in 
the  bladder- wall.  The  two  dilatations  which  lie  between  the  three 
contractions  are  frequently  called  the  upper  and  the  lower  spindles. 


Fig.  82. — Specimen  illustrating  one  of  the  causes  of  imperforate  anus.  S,  Sigmoid 
flexure  and  descending  colon,  terminating  in  a  blind  pouch  (R),  corresponding  to  the  rec- 
tum, which  communicated  by  a  slit-like  opening  with  B,  rudimentary  bladder.  K,  Kidney. 
U,  Dilated  ureter.  C,  Clitoris.  A,  Dilated  hollow  viscus,  communicating  through  a  wide 
opening  with  B,  bladder,  and  probably  corresponding  to  the  dilated  urachus. 


285 


THE    PELVIS    IN   GENERAL.  287 

The  former  lies  in  the  abdomen,  the  latter  in  the  pelvis.     The  ureters 
converge  as  they  descend  in  the  abdomen. 

The  Pelvis  in  General. 

The  pelvis  is  formed  by  the  innominate  bones  and  the  sacrum. 
It  is  divided  into  the  false  pelvis,  lying  above  the  iliopectineal  lines, 
and  the  true  pelvis,  lying  below  them.  The  false  pelvis  was  taken 
up  in  connection  with  the  iliac  fasciae.  The  true  pelvis  has  an  inlet,  or 
superior  aperture,  which  is  cordate  in  the  male  and  more  oval  in  the 
female.  The  true  pelvis  also  has  an  outlet  or  inferior  aperture.  Of 
clinical  interest  in  the  inlet  is  the  anteroposterior  or  conjugate  diame- 
ter, which  is  of  great  use  in  obstetrics  as  an  index  to  the  size  of  the 
pelvis,  and  also  the  oblique  diameters,  taken  from  the  sacro-iliac  joint 
of  one  side  to  the  iliopectineal  eminence  of  the  other.  The  transverse 
diameter  of  the  inlet  is  taken  across  the  point  of  greatest  width. 

The  position  of  the  pelvis  in  the  living,  when  the  figure  is  erect,  may 
be  approximately  represented  by  placing  it  so  that  the  anterior  superior 
iliac  spines  and  the  symphysis  pubis  lie  in  the  same  vertical  plane.  On 
an  average  it  forms  an  angle  of  from  50  to  60  degrees  with  the  horizon. 

The  outlet  of  the  pelvis  has  as  its  boundaries  the  pubic  arch,  or  rami 
of  the  ischium,  the  tuberosities  of  the  ischium,  and  the  coccyx. 

In  the  same  manner  as  was  seen  in  the  case  of  the  bony  thorax,  the 
pelvis  may  be  changed  in  its  diameters  as  the  result  of  joint  or  local 
diseases.  Of  the  general  diseases,  those  most  frequently  affecting  it 
are  osteomalacia  and  rickets.  Among  the  local  conditions  are  unilateral 
or  bilateral  congenital  dislocation  of  the  hip  (see  Fig.  134),  or  those  due 
to  disease  of  the  vertebrae  or  hip-joint,  or  to  injury  or  disease  of  the 
pelvic  bones. 

The  most  important  joint  in  connection  with  the  pelvis  is  the  sacro- 
iliac  joint  (see  Fig.  77).  Externally,  the  posterior  spine  of  the  ilium 
corresponds  to  the  middle  of  this  joint.  The  capsule  of  the  joint  is 
formed  by  ligaments  which  lie  in  front  and  back  of  it  and  the  synovial 
cavity  is  very  imperfect  and  rudimentary.  It  is  frequently  the  seat  of 
tubercular  infection. 

Just  below,  and  to  its  outer  side  in  the  pelvis,  lies  the  great  sacro- 
sciatic  notch,  through  which  the  principal  branches  of  the  sacral  plexus 
which  go  to  form  the  sciatic  nerve  pass,  so  that  these  nerves  are  in  close 
proximity  to  the  joint. 

The  pelvic  fascia  is  a  continuation  of  the  iliac  fascia;  it  lines  the  pel- 
vic wall.  From  its  outer  surface  arises,  behind,  the  pyriformis  muscle,  and 
at  the  sides  of  the  pelvis  the  obturator  internus  (see  Figs.  77  and  90).  Be- 


288  THE    ABDOMEN. 

tween  the  back  of  the  pubis  and  the  spine  of  the  ischium,  to  both  of  which 
the  pelvic  fascia  is  attached,  extends  a  thickened  band  of  the  fascia,  called 
the  white  line.  It  gives  origin  to  the  fibers  of  the  levator  ani  muscle  (see 
Fig.  88)  and  sends  off  a  visceral  layer  which  arches  downward  and 
inward  and  crosses  the  floor  of  the  pelvis  to  support  the  pelvic  viscera. 
The  internal  iliac  vessels  and  their  branches  lie  on  the  inner  aspect 
of  the  pelvic  fascia,  the  sacral  plexus  lies  on  its  outer  aspect.  In  the 
female  the  pelvic  fascia,  instead  of  inclosing  the  prostate  gland,  incloses 
the  neck  of  the  bladder  and  the  vagina.  It  also  invests  the  lower  part 
of  the  uterus  instead  of  the  seminal  vesicles.  Any  suppuration  from  the 
pelvic  organs,  prostate,  bladder,  rectum,  etc.,  which  escapes  beneath 
the  visceral  layer  of  the  pelvic  fascia,  will  be  limited  in  its  course  upward 
by  the  attachment  of  the  levator  ani,  whereas  any  suppuration  above 
this  layer  can  readily  escape  to  the  subperitoneal  connective  tissue  and 
spread  in  all  directions.  On  account  of  the  attachment  of  the  parietal 
layer  of  the  pelvic  fascia  to  the  sides  of  the  pelvis,  pus  migrating  down- 
ward from  the  abdominal  cavity  will  be  limited  in  its  spread  by  the 
attachments  of  this  fascia,  unless  it  breaks  through,  it,  when  it  can 
pass  to  the  perineum. 

Relations  of  Pelvic  Viscera. 

The  best  idea  of  the  relations  of  the  pelvic  organs  in  the  male  and 
female,  to  each  other  and  to  the  walls  of  the  pelvis,  can  be  obtained 
by  a  study  of  sections  made  in  various  directions,  as  well  as  a  view 
from  above  and  below  of  the  pelvic  organs  lying  in  their  normal  rela- 
tions. For  the  male  pelvis,  an  inspection  of  figures  69,  71,  83,  84,  85, 
and  90  is  suggested. 

The  bladder  in  the  male,  when  empty,  lies  immediately  behind 
the  symphysis  pubis  (Fig.  83)  and  has  the  form  of  an  inverted 
tetrahedron.  The  base  of  the  triangle,  or  superior  surface  of  the 
bladder,  faces  the  general  peritoneal  cavity,  and  its  apex  corresponds 
to  the  orifice  of  the  urethra.  The  bladder  is  firmly  held  in  place  on 
its  anterior  aspect  by  the  puboprostatic  ligaments  running  to  the  sides 
of  the  pelvis,  and  the  ligament  (U  in  figure  69),  called  the  anterior  liga- 
ment, which  contains  the  remains  of  the  urachus.  The  upper  portion 
of  the  bladder  has  the  ability  to  change  its  shape  as  the  bladder  becomes 
fuller.  In  doing  so  it  raises  the  fold  of  peritoneum  (PE  in  Figs.  71 
and  83),  so  that  when  the  bladder  is  fully  distended,  this  reflection  of 
peritoneum  is  raised  a  distance  of  i  J  to  2  inches  above  the  upper  margin 
of  the  pubis,  and  access  can  be  had  to  the  bladder  without  entering 
the  peritoneal  cavity.  This  anatomic  fact  is  utilized  in  the  operation 


Fig.  83. — Sagittal  section  of  pelvis  showing  widths  of  different  portions  of  the  urethra, 
and  the  relation  of  the  structures  at  the  base  of  the  bladder  to  the  rectum,  i  Fossa  navic- 
ularis.  2,  Bulbous  portion  of  urethra.  3,  Membranous  portion  of  urethra.  4,  Prostatic 
portion  of  urethra  (note  its  direction),  ending  in  the  bladder.  C.R,  Connective-tissue 
space  between  peritoneum  and  abdominal  wall.  P.E.,  Peritoneum  covering  superior  sur- 
face of  bladder.  G.,  Prostate  gland.  R.,  Rectum.  S.,  Internal  sphincter.  P.,  Pubic 
arch.  T.,  Median  raphe  of  scrotum,  separating  the  testes.  A.L.,  Anterior  layer  triangu- 
lar ligament.  P.L.,  Posterior,  layer  triangular  ligament. 


289 


RELATIONS    OF    PELVIC    VISCERA.  291 

known  as  suprapubic  cystotomy.  Even  when  the  bladder  is  full  and 
rises  out  of  the  pelvis,  the  base  or  lower  portion  of  the  bladder  remains 
stationary  and  in  its  normal  relation  to  the  rectum  and  the  structures 
at  its  base.  The  peritoneum  (Figs.  69,  71,  and  83),  after  covering 
the  superior  surface  of  the  bladder,  makes  a  slight  downward  dip 
between  the  bladder  and  the  rectum,  and  then  covers  the  anterior  and 
a  portion  of  the  lateral  surfaces  of  the  rectum.  When  the  bladder  is 
full,  this  rectovesical  pouch,  as  it  is  called,  becomes  relatively  deeper. 
The  superior  surface  of  the  bladder  has  lying  upon  it  coils  of  the  ileum 
and  pelvic  colon.  The  posterior  surface  of  the  bladder  is  in  contact  with 
the  ampulla  of  the  rectum,  being  separated  from  it  only  (see  Figs.  83 
and  84)  by  loose  cellular  tissue,  the  levatores  ani  muscles,  and  below  by 
the  internal  sphincter  and  the  structures  at  the  base  of  the  bladder. 
These  structures  at  the  base  of  the  bladder  are  the  seminal  vesicles 
(well  shown  in  Fig.  84)  and  the  terminations  of  the  vasa  deferentia  on 
each  side. 

Laterally,  in  contact  with  the  side  of  the  bladder,  is  the  ureter 
(see  U  in  Figs.  71  and  84),  which,  after  crossing  the  pelvic  brim  in  the 
male,  passes  downward  and  backward  along  the  side  wall  of  the  pelvis 
to  a  point  about  one  inch  to  an  inch  and  a  half  in  front  of  the  spine  of 
the  ischium,  lying  immediately  in  front  of  the  internal  iliac  artery.  The 
ureter,  before  reaching  the  bladder,  is  covered  by  peritoneum,  which 
separates  it  from  the  pelvic  colon  on  the  left,  and  from  the  terminal 
portion  of  the  ileum  on  the  right.  It  runs  forward  and  inward  from 
the  side  wall  of  the  pelvis,  lying  upon  the  upper  surface  of  the  levator 
ani  on  each  side.  Before  it  reaches  the  bladder  it  is  crossed  in  front 
by  the  vas  deferens,  which  passes  between  it  and  the  side  wall  of  the 
bladder,  and  it  enters  the  bladder  wall  immediately  in  front  of  the 
upper  end  of  the  seminal  vesicle  (see  Figs.  71  and  83). 

Ordinarily  the  bladder  holds  from  six  to  ten  ounces  in  the  adult 
male,  but  it  may  contain  one  pint. 

The  mucous  membrane  of  the  bladder  is  continuous  with  that  of 
the  ureters  and  of  the  urethra.  The  ureters  pass  obliquely  through 
the  bladder  (see  Fig.  83),  so  that  when  the  bladder  is  full,  it  closes  the 
openings  of  the  ureters  and  prevents  further  access  of  urine.  The 
internal  orifice  of  the  urethra  is  situated  immediately  beneath  the 
pubis.  When  the  bladder  is  empty,  this  orifice  corresponds  to  the 
apex  of  the  inverted  tetrahedron  which  the  empty  bladder  forms.  It 
does  not  change  its  position  when  the  bladder  is  full,  being  quite  firmly 
fixed  by  the  puboprostatic  ligaments  to  the  pubes.  The  superior 
surface  of  the  bladder  is  usually  called  the  jundus;  that  portion  of  the 


2Q2  THE    ABDOMEN. 

bladder  which  faces  the  rectum  and  structures  between  the  bladder 
and  rectum  is  called  the  base,  and  where  the  bladder  suddenly  narrows 
to  form  the  internal  orifice  of  the  urethra  is  called  the  neck.  The 
mucous  membrane  of  the  bladder  is  only  loosely  connected  to  the 
underlying  muscle. 

At  the  base  of  the  bladder  the  mucosa  is  firmly  attached  over  a 
triangular  area  known  as  the  trigone,  whose  apex  corresponds  to  the 
internal  orifice  of  the  urethra,  and  the  angles  of  the  base  correspond 
to  the  orifice  of  the  ureters.  The  minute  opening  of  each  ureter 
has  an  elliptical  outline.  The  sides  of  the  trigone  form  an  approx- 
imate equilateral  triangle,  each  of  the  sides  being  about  one  inch  in 
length. 

On  account  of  its  well-protected  position  behind  the  pubis,  the 
bladder  when  empty  is  seldom  exposed  to  injury,  except  in  fractures 
of  the  pelvis,  when  it  may  be  punctured  by  one  of  the  fragments.  When 
full,  the  bladder  is  far  more  subject  to  injury,  being  then,  to  some 
extent,  an  abdominal  organ.  In  children  the  bladder  always  rises  out 
of  the  pelvis  when  full.  (See  Fig.  23.)  A  rupture  of  the  bladder  may 
occur,  independent  of  any  fracture.  If  at  the  fundus  of  the  bladder  or 
close  to  the  rectovesical  pouch,  the  urine  escapes  into  the  general  peri- 
toneal cavity;  if  at  the  base  or  anterior  or  lateral  surface  below  the  re- 
flection of  the  peritoneum,  it  escapes  into  the  loose  cellular  tissue  (see  Fig. 
90)  between  the  peritoneum  and  pelvic  fascia.  Hence  the  latter  (extra- 
peritoneal  rupture)  gives  rise  to  a  smaller  mortality  than  the  former 
(intraperitoneal  rupture). 

In  enlarged  conditions  of  the  prostate  the  base  of  the  bladder  may 
be  elevated  just  behind  the  urethral  orifice  and  cause  the  musculature 
to  be  greatly  hypertrophied,  the  mucous  membrane  often  bulging 
between  the  trabeculae,  or  ridges  formed  by  the  hypertrophied  muscle. 
Such  diverticula  may  be  punctured  through  the  careless  use  of  instru- 
ments in  the  aged.  At  the  base  of  the  bladder  a  pouch  forms  behind  the 
hypertrophied  prostate  in  which  a  portion  of  the  urine  lies  and  cannot 
be  expelled.  This  urine  which  is  left  behind  at  each  urination  is  called 
residual  urine,  and  it  readily  decomposes,  giving  rise  to  an  inflam- 
mation of  the  bladder,  or  cystitis.  All  forms  of  cystitis  may,  through 
migration  of  the  organisms  along  the  ureters  into  the  pelvis  of  the 
kidney,  give  rise  to  a  condition  known  as  pyelonephritis,  formerly 
called  surgical  kidney,  the  effect  upon  the  system  being  that  of  an 
acute  or  chronic  toxemia,  called  urosepsis. 

The  seminal  vesicles  and  vasa  deferentia  are  covered  by  peri- 
toneum close  to  the  entrance  of  the  ureters  into  the  bladder.  Thev 


Fig.  84. — Dissection  of  base  of  male  bladder.  B,  Bladder.  D,  Vas  deferens.  U, 
Ureters.  Upon  the  right  side  the  ureter  is  seen  to  disappear  obliquely  through  the  coats  of 
the  bladder,  a  little  above  the  upper  end  of  the  seminal  vesicles  (SV).  Upon  the  left  side 
its  entrance  through  the  bladder-wall  is  concealed  by  the  upper  end  of  the  seminal  vesicle. 
SV,  Seminal  vesicle.  P,  Prostate  gland,  showing  lateral  lobes.  M,  Membranous  portion 
of  urethra.  T,  Anterior  layer  of  triangular  ligament.  I,  Ascending  ramus  of  ischium  and 
descending  ramus  of  pubis. 


293 


RELATIONS    OF    PELVIC    VISCERA.  295 

converge  toward  the  median  line  and  their  duct  enters  the  prostatic 
portion  of  the  urethra  on  either  side  of  the  median  line,  so  that  in  re- 
moval of  the  prostate  an  injury  of  the  ducts  is  almost  unavoidable. 

Around  the  neck  of  the  bladder  there  is  a  rich  plexus  of  veins  known 
as  the  prostatic  plexus,  which  frequently  become  so  congested  as  to 
become  varicose,  giving  rise  to  either  spontaneous  hemorrhages  into 
the  bladder  or  to  severe  bleeding  during  catheterization,  especially  in 
the  aged. 

The  male  urethra,  from  the  internal  orifice  at  the  bladder,  called 
the  internal  meatus,  to  the  external  meatus,  measures  about  eight  inches 
in  length,  and  is  divided  (from  the  bladder  outward)  into  three  portions 
—a  prostatic,  a  membranous,  and  a  pendulous  or  spongy.  The  first  part, 
or  prostatic,  lies  within  the  pelvic  cavity  and  has  an  almost  vertical 
course  (see  Fig.  83)  as  it  traverses  the  prostate.  The  prostatic  portion 
has  opening  into  it  the  orifices  of  numerous  prostatic  glands  on  each  side 
of  a  median  ridge  or  elevation  on  its  floor  or  posterior  wall.  On  each 
side  of  a  little  depression  in  this  ridge  (prostatic  utricle)  open  the  ejacu- 
latory  ducts.  The  membranous  portion  of  the  urethra  lies  between 
the  deep  or  posterior  and  the  superficial  or  anterior  layers  of  the  tri- 
angular ligament  (see  Figs.  83  and  84).  It  is  surrounded  by  the  fibers 
of  the  compressor  urethrae  muscle,  which  also  lies  between  the  folds 
of  the  ligament,  and  by  Cowper's  glands  (see  Figs.  83  and  85).  This 
portion  of  the  urethra  leads  downward  and  forward  to  the  third  01 
pendulous  portion.  The  membranous  portion  is  the  most  fixed  part 
of  the  urethra,  and  in  falls  upon  the  perineum,  or  in  fractures  of  the 
pelvis,  especially  of  the  symphysis  pubis,  it  is  most  likely  to  be  either 
partly  or  completely  ruptured.  The  spongy,  often  called  the  pen- 
dulous portion  of  the  urethra,  is  surrounded  through  its  whole  extent 
by  the  erectile  tissue  of  the  corpus  spongiosum.  When  the  penis  is  in 
contact  with  the  scrotum,  the  bulbous  or  proximal  dilated  end  of  the 
pendulous  urethra  looks  upward  and  forward,  the  remainder  of  the 
pedulous  urethra  (see  Fig.  83)  downward  and  forward.  In  order 
to  catheterize  or  to  pass  sounds,  it  is  necessary  to  bear  in  mind  the 
curve  of  the  urethra.  In  passing  such  an  instrument,  the  penis 
should  be  at  first  held  upward  so  that  the  entire  length  of  the  pendulous 
portion  looks  upward  and  forward.  As  soon  as  the  instrument  meets 
with  resistance  (anterior  layer  of  triangular  ligament)  the  instrument 
and  penis  should  be  lowered  so  that  the  tip  of  the  instrument  can  follow 
the  almost  vertical  upward  course  of  the  membranous  and  prostatic 
portions  of  the  urethra.  These  instructions  will  be  readily  understood 
by  a  reference  to  figure  83. 


296  THE    ABDOMEN. 

Clinically,  the  urethra  is  divided  into  two  parts,  the  anterior  portion 
extending  from  the  external  meatus  to  the  anterior  layer  of  the  tri- 
angular ligament — that  is,  where  one  first  meets  with  a  resistance  due 
to  the  spasmodic  contraction  of  the  compressor  urethrae  muscle  lying 
between  the  layers  of  the  triangular  ligament;  the  second  portion  is 
the  posterior  portion,  which  embraces  the  membranous  and  prostatic 
portions  of  the  urethra.  In  gonorrheal  inflammation  it  is  important 
to  bear  this  distinction  in  mind,  as  many  cases  are  limited  to  the  anterior 
portion;  others  extend  over  both  anterior  and  posterior  portions  of 
the  urethra. 

The  mucous  membrane  lining  the  pendulous  portion  contains  a 
large  number  of  glands  or  crypts  called  the  glands  of  Littre,  as  well 
as  the  orifices  into  the  bulbous  portion  of  the  glands  of  Cowper,  referred 
to  above. 

The  prostatic  portion  of  the  urethra  is  about  ij  to  ij  inches  in 
length;  that  of  the  membranous  portion,  |  of  an  inch  to  i  inch,  and  of 
the  penile  or  pendulous  portion  6J  inches,  making  an  average  total 
length  of  8J  inches.  As  will  be  seen  by  a  reference  to  figure  83,  the 
caliber  of  the  urethra  varies  in  its  different  portions,  being  widest  in 
the  bulbous  portion  and  at  the  fossa  navicularis,  and  narrowest  at  the 
external  meatus  and  membranous  portion. 

The  size  of  steel  sound  which  the  normal  urethra  admits  is  as 
follows : 

1.  Meatus  urinarius 21  to  28  French. 

2.  Fossa  navicularis 30  to  33  " 

3.  Middle  of  pendulous  portion 27  to  30  " 

4.  Bulbous  portion 33  to  36  " 

5.  Membranous  portion 27  " 

6.  Apex  of  prostatic  portion 30  " 

7.  Middle  of  prostatic  portion 45  " 

8.  Base  of  prostatic  portion 33  " 

From  the  anatomy  of  the  urethra,  the  complications  of  gonorrhea 
can  be  readily  understood.  Infiltration  of  the  mucous  membrane  and 
cicatrization  of  the  infiltrated  area,  with  subsequent  narrowing  of  the 
canal,  may  exist  at  any  portion,  but  is  most  frequent  at  the  junction  of 
the  bulbous  (end  of  spongy)  and  membranous  portions  of  the  urethra.  It 
is  extremely  rare  in  the  prostatic  portion  of  the  urethra.  The  inflam- 
mation may  invade  the  many  glands  of  Littre  and  cause  casts  of  the 
same  to  be  present  in  the  urine  in  the  form  of  so-called  "clap  shreds." 
The  fact  that  the  prostatic  glands  and  the  orifices  of  the  ejaculatory 
ducts  open  into  the  prostatic  portion  of  the  urethra  will  explain  a  fre- 


RELATIONS    OF    PELVIC    VISCERA.  297 

quent  complication  in  the  form  of  an  inflammation  of  the  prostate, 
even  leading  to  abscess  of  the  same.  It  also  explains  an  inflammation  of 
the  seminal  vesicles,  vasa  deferentia,  and  their  continuation  into  the  epi- 
didymis  and  testis  of  each  side  (see  Figs.  71,  83,  and  84).  (Acute  or 
chronic  gonorrheal  prostatitis,  vesiculitis,  deferentitis,  cystitis,  and  epi- 
didymitis.)  The  infection  may  even  extend  into  the  ureter  and  to  the 
kidney  (gonorrheal  ureteritis  and  pyelitis). 

The  prostate  gland  is  a  partly  glandular  and  partly  muscular  organ, 
surrounding  the  beginning  of  the  male  urethra.  It  lies  within  the  pelvis 
inclosed  in  a  dense  capsule  derived  from  the  pelvic  fascia.  Its  size 
varies  greatly,  being  usually  i  J  to  i  J  inches  in  length,  the  antero-posterior 
diameter  f  of  an  inch,  and  the  vertical  diameter  about  ij  inches  (see 
Figs.  83  and  84).  The  apex  of  the  prostate  is  directed  downward  and 
its  base  is  directed  upward  against  the  under  aspect  of  the  neck  of  the 
bladder,  being  continuous  with  the  bladder- wall.  The  lateral  surfaces 
of  the  prostate  are  convex  and  prominent  (see  Fig.  84),  the  posterior 
surface  is  separated  from  the  anterior  wall  of  the  rectum  by  a  layer  of 
pelvic  fascia.  The  prostate  is  penetrated  by  the  urethra  and  the 
ejaculatory  ducts.  That  portion  of  the  prostate  which  lies  between 
the  ducts  and  the  posterior  aspect  of  the  urethra  is  called  the  middle 
lobe ;  in  old  age  it  may  enlarge  to  such  an  extent  as  to  be  the  chief  source 
of  obstruction  in  hypertrophied  prostate,  forming  a  valve-like  opening 
in  front  of  the  internal  orifice  of  the  urethra  which  prevents  urine  from 
escaping.  It  then  causes  a  considerable  elevation  in  the  median  line 
of  the  bladder.  The  greater  portion  of  the  prostate  is  composed  of 
two  lateral  lobes  (see  Fig.  84)  separated  by  an  indistinct  groove.  These 
lobes  are  frequent  seats  of  hypertrophy.  When  they  are  enlarged, 
the  course  of  the  prostatic  portion  of  the  urethra  may  be  either 
to  the  left  or  right  of  the  median  line  and  greatly  elongated,  ac- 
cording to  which  side  is  enlarged.  When  both  lobes  are  enlarged,  the 
prostatic  portion  of  the  urethra  is  not  only  lengthened  so  that  the  total 
length  of  the  urethra  may  reach  ten  inches,  but  the  enlarged  prostate 
forms  an  almost  absolute  obstruction  to  the  exit  of  urine.  When  the 
middle  and  lateral  lobes  of  the  prostate  are  all  enlarged,  the  prostatic 
portion  of  the  urethra  may  divide  at  the  middle  lobe,  one  groove  run- 
ning to  each  side  of  it. 

The  prostate  is  surrounded  by  large  plexuses  of  veins  into  which 
the  veins  of  the  penis  open,  called  the  prostatic  plexus  which  empty 
into  the  vesical  plexus  of  veins.  These  give  rise  to  severe  hemorrhage 
during  a  prostatectomy. 

The  vas  deferens,  if  followed  from  the  base  of  the  bladder,  on  either 


2p8  THE    ABDOMEN. 

side,  lies  extraperitoneally  during  its  entire  course  to  the  internal  ab- 
dominal ring  (see  Figs.  69  and  71).  Its  entire  length  is  about  eighteen 
inches,  but  the  actual  distance  traversed  by  it  is  not  more  than  twelve 
inches.  From  the  base  of  the  bladder  it  passes  upward  to  the  side  wall  of 
the  pelvis  (see  Figs.  69,  71,  and  84).  After  crossing  the  pelvic  brim  it 
unites  along  the  inner  side  of  the  iliac  vessels  with  the  spermatic  vessels. 

These  structures  and  the  accompanying  nerves  and  loose  coverings 
derived  from  certain  layers  of  the  abdominal  wall  (infundibuliform 
fascia  and  cremaster  muscle)  form  the  spermatic  cord. 

The  spermatic  cord  passes  through  the  inguinal  canal  on  either  side 
(see  Figs.  69  and  71),  entering  the  scrotum  at  the  external  abdominal  ring. 
It  can  be  readily  detected  during  life  by  its  hard,  firm,  cord-like  feeling 
when  it  is  held  between  the  fingers  and  thumb.  The  spermatic  cord 
always  lies  behind  and  to  the  outer  side  of  an  inguinal  hernia  sac. 

The  vas  deferens  at  its  lower  end  joins  with  the  seminal  vesicles, 
which  are  intimately  related  to  the  wall  of  the  bladder,  being  separated 
at  the  upper  ends  by  the  rectovesical  pouch  of  peritoneum.  They 
serve  as  reservoirs  for  the  testicular  secretion. 

At  its  outer  or  scrotal  end  the  spermatic  cord  ends  in  the  epididymis. 
This  latter  structure  sits  like  a  cap  upon  the  posterior  part  of  the  outer 
surface  of  the  testis.  Its  upper  portion  is  called  the  globus  major,  or 
head  of  the  epididymis.  The  lower  and  smaller  end,  into  which  the 
vas  deferens  enters,  is  called  the  tail,  or  globus  minor.  The  intervening 
part  is  called  the  body  of  the  epididymis. 

The  testis,  like  the  epididymis  and  the  extra-abdominal  portion  of  the 
vas  deferens,  is  placed  one  on  each  side  within  the  cavity  of  the  scrotum 
(Fig.  71).  It  is  an  oval  body  about  an  inch  and  a  half  in  length,  with  its 
long  axis  directed  upward  and  outward.  Its  two  surfaces  are  covered 
by  a  reflection  of  a  serous  surface  called  the  tunica  vaginalis.  This 
is  a  remnant  of  the  original  sac  of  peritoneum  which  accompanies 
the  testis  in  its  descent,  and  is  in  reality  a  continuation  of  peritoneum. 
Its  cavity  contains,  under  normal  conditions,  a  small  amount  of  serum. 
Under  pathologic  conditions  this  serum  may  accumulate,  giving  rise 
to  a  hydrocele  which  always  lies  on  the  anterior  and  inner  side  of  the 
testis.  The  testis  and  epididymis,  as  well  as  the  greater  portion  of  the 
spermatic  cord,  are  supplied  by  the  spermatic  arteries  and  veins. 

Both  spermatic  arteries  arise  from  the  aorta  (see  Fig.  71)  below 
the  renals.  The  right  spermatic  vein  arises  from  the  vena  cava,  the 
left  spermatic  vein  from  the  left  renal.  The  fact  that  the  origin  of 
these  veins  is  so  far  from  the  source  of  emptying  their  blood,  and 
that  they  are  not  provided  with  valves,  renders  stagnation  of  blood  in 


THE    RECTUM.  299 

them  in  the  erect  position  of  the  body  easily  possible.  This  is  especially 
true  of  the  left  side,  where  the  spermatic  vein  enters  the  renal  at  right 
angles,  forming  an  additional  mechanical  obstruction.  Hence  vari- 
cosities  of  the  spermatic  or  pampiniform  plexus  of  veins  in  the  male 
are  more  frequent  on  the  left  than  upon  the  right  side  of  the  body. 
This  condition  is  clinically  known  as  varicocele. 

Descent  of  the  Testis. — The  testes  during  early  embryonic  life  lie  on 
the  posterior  wall  of  the  abdomen  in  the  neighborhood  of  the  kidney. 
Toward  the  end  of  the  seventh  month  they  lie  near  the  abdominal  ring, 
having  pulled  the  spermatic  artery  and  vein  with  them.  Meanwhile  a 
blind  pouch,  or  diverticulum  of  the  peritoneal  sac,  called  the  vaginal  pro- 
cess, has  grown  downward  and  inward  through  the  anterior  abdominal 
wall  toward  the  scrotum.  It  is  accompanied  by  the  testis  with  its  vessels ; 
the  testis  being  accompanied  by  a  cord-like  structure,  the  gubernaculum 
testis.  This  gubernaculum,  at  its  greatest  development,  about  the 
sixth  month,  is  attached  above  to  the  lower  end  of  the  testis,  while 
below  it  is  fixed  near  the  inguinal  region.  As  the  testis  accompanies 
the  vaginal  process,  the  gubernaculum  atrophies,  and  its  failure  to  at- 
rophy may  have  much  to  do  with  the  abnormal  positions  of  the  testis 
which  occur.  The  testis  may  be  found  abnormally  (cryptorchismus) 
within  the  abdominal  cavity,  within  the  inguinal  canal,  and  occasion- 
ally in  the  groin,  or  even  in  the  perineum.  If  in  the  abdomen,  it  sel- 
dom develops,  remaining  atrophied  throughout  life.  If  within  the  in- 
guinal canal,  it  is  greatly  exposed  to  injury  and  frequently  gives  rise  to 
malignant  growths  (sarcoma).  These  abnormal  positions  of  the  testis 
are  spoken  of  as  cryptorchismus. 

The  Rectum. 

The  rectum  in  the  male  is  separated  from  the  bladder  by  the  recto- 
vesical  connective  tissue  and  the  reflection  of  peritoneum  covering  the 
same.  It  is  only  covered  to  a  partial  extent  on  its  anterior  and  lateral 
walls  by  peritoneum.  As  a  rule,  only  the  upper  two-thirds  is  covered, 
the  lower  third  having  no  peritoneal  investment.  This  reflection— 
that  is,  the  bottom  of  the  rectovesical  pouch — is  about  one  inch  above 
the  prostate,  or  three  inches  above  the  anus.  It  is  relatively  much 
higher  in  fatty  subjects,  while  it  is  usually  lower  in  emaciated  ones. 
The  rectum  begins  about  the  middle  of  the  sacrum  (the  third  sacral 
vertebra)  and  ends  in  the  anal  canal  or  anus,— the  third  portion  of  the 
rectum  of  old  descriptions, — at  the  level  of  the  lower  edge  of  the  levator 
ani  muscles  (see  Fig.  42).  The  rectum  proper  (second  portion  of  the 
rectum  of  old  descriptions)  has  three  more  or  less  distinct  lateral 
19 


300  THE    ABDOMEN. 

bends.  These  are  marked  on  the  exterior  by  a  crease  and  on  the 
interior  as  three  crescentic  shelves  of  mucous  membrane  known  as 
the  rectal  valves  of  Houston  or  Kohlrausch.  These  are  of  considerable 
importance  in  supporting  the  fecal  contents  when  the  rectum  is  dis- 
tended. One  of  them  is  shown  in  figure  78.  When  the  rectum  is 
empty,  its  course  is  comparatively  straight,  and  to  each  side  of  it  is  a 
large  fossa  of  peritoneum  containing  a  mass  of  small  intestine,  or  the 
pelvic  colon.  When  the  rectum  is  full,  this  pararectal  fossa  is  ob- 
literated. Just  before  passing  into  the  anal  canal,  the  rectum  is  greatly 
dilated  to  form  the  ampulla  of  the  rectum  (see  Fig.  42).  The  front 
of  the  rectum,  measured  from  the  anus,  or  external  opening  of  the 
anal  canal,  has  no  peritoneal  covering  for  a  distance  of  three  inches. 
The  posterior  aspect  is  not  covered  by  peritoneum  for  five  or  six  inches. 
In  front  and  above,  the  peritoneum  is  closely  adherent;  at  the  sides 
and  below,  it  is  much  looser.  The  rectum  rests  upon  the  front  of  the 
sacrum  and  coccyx,  and  below  these  upon  the  posterior  part  of  the 
pelvic  floor  formed  by  the  meeting  of  the  two  levator  ani  muscles  (Fig. 
90).  In  front,  it  is  separated  from  the  bladder  (Fig.  83).  The  anal 
canal,  or  third  portion  of  the  rectum  of  the  old  descriptions,  begins 
where  the  rectum  proper  terminates,  at  the  level  of  the  meeting  of 
the  levator  ani  muscles  in  the  median  line.  It  is  usually  about  i  to 
ij  inches  long,  and  is  directed  down  and  backward.  It  is  surrounded 
by  the  external  and  internal  sphincters  below,  and  above  by  the  lower 
edge  of  the  levator  ani.  On  each  side  of  it  is  situated  the  ischiorectal 
fossa  with  its  mass  of  fat  (Fig.  90).  Behind,  it  is  separated  from 
the  coccyx  by  a  quantity  of  mixed  connective  and  muscular  tissue.  In 
front,  it  is  in  close  relation  with  the  bulbous  and  membranous  portions 
of  the  urethra,  and  the  distance  to  which  a  sound  has  entered  in  the 
urethra  can  be  controlled  by  a  finger  introduced  into  the  anal  canal 
(Fig.  83).  The  sphincters  of  the  rectum  and  anal  portion  are  the 
levatores  ani  and  internal  and  external  sphincters.  The  first-named 
act  like  clamps  which  support  the  distended  rectum  immediately  above 
the  anal  canal,  and  in  this  way  suspend  the  weight  of  the  feces  when 
the  rectum  is  distended.  They  are  voluntary  muscles.  The  external 
sphincter  forms  a  muscular  cylinder  around  the  upper  two-thirds  of 
the  anal  canal,  being  attached  in  front  to  the  median  raphe  of  the 
perineum  (central  point  in  Fig.  85)  and  behind  to  the  coccyx  (Fig.  85). 
It  is  the  principal  sphincter  of  the  anus,  or  external  opening  of  the 
anal  canal,  and  under  ordinary  circumstances  is  in  a  state  of  chronic 
contraction,  so  that  the  finger  can  only  be  inserted  with  difficulty  into 
the  anal  canal.  The  internal  sphincter  is  merely  a  thickening  of  the 


THE    RECTUM.  301 

circular  muscular  coat  at  the  end  of  the  bowel,  and  its  chief  use  is  to 
empty  the  anal  canal  completely.  It  probably  acts  more  as  a  detrusor 
or  expeller  than  as  a  true  sphincter,  the  principal  sphincter  action  being 
maintained  by  the  external  sphincter.  In  the  interior  of  the  anal 
canal  one  notices  the  vertical  folds  of  mucous  membrane  which  are 
prominent  in  character  (containing  an  artery  and  a  vein)  galled  the 
columns  of  Morgagni,  and  it  is  here  that  hemorrhoidal  enlargements 
(internal)  are  most  likely  to  appear.  Between  the  two  adjacent 
columns  there  is  a  small  transverse  crescentic  valve-like  fold  which 
joins  the  end  of  the  two  columns.  Behind  each  is  found  a  little  pocket, 
in  which  foreign  particles  often  lodge.  The  epidermis  around  the  anus 
is  continued  inward  as  far  as  the  margins  of  the  anal  valves,  the  junc- 
tion being  indicated  by  a  fine  wavy  line.  On  account  of  the  relation  of 
the  ischiorectal  fossa  to  the  sides  of  the  rectum  and  anal  portion  of 
the  rectum,  abscesses  are  likely  to  occur  in  it,  due  to  perforation  of  the 
wall  of  the  rectum  by  some  foreign  body,  or  the  migration  of  organ- 
isms through  the  intact  mucous  membrane.  Such  abscesses  point  ex- 
ternally at  the  side  of  the  anus  (ischiorectal  abscess). 

The  rectum  and  anal  canal  receive  their  blood-supply  from  the 
three  (superior,  middle,  and  inferior)  hemorrhoidal  arteries  of  each 
side  and  from  the  middle  sacral  artery.  The  veins  are  of  the 
same  name,  the  chief  point  of  interest  being  that  the  superior  and 
middle  empty  into  the  portal  circulation,  whereas  the  inferior  empty 
into  the  internal  iliac,  a  tributary  of  the  vena  cava.  Thus  an 
anastomosis  exists  between  the  two  circulations.  Any  obstruction 
in  the  portal  circulation  causes  the  appearance  of  varices  in  the 
rectum  (hemorrhoids).  The  inner  wall  of  the  ischiorectal  fossa  is 
formed  by  the  levator  ani  and  coccygeal  muscles,  covered  by  the  anal 
fascia;  the  outer  wall  by  the  obturator  internus,  covered  by  the  obturator 
fascia  (Fig.  90).  If  an  abscess  in  the  ischiorectal  fossa  is  not  opened 
at  the  base,  lateral  to  the  anus,  it  may  perforate  the  levator  ani  toward 
the  apex  of  the  fossa,  which  lies  2}  inches  from  the  surface,  and  burrow 
into  the  cellular  tissue  of  the  pelvis  around  the  rectum,  opening  into 
the  ampulla;  or  it  may  burrow  upward  in  the  peritoneal  fatty  tissue 
of  the  pelvis  and  ascend  in  it  to  form  an  iliac  abscess.  The  lymphatics 
from  the  skin  of  this  entire  region  pass  to  the  inguinal  and  crural  glands, 
although  those  of  the  rectum  itself  pass  to  the  retrorectal  cellular 
tissue  in  front  of  the  sacrum  and  to  the  glands  in  the  neighborhood  of 
the  internal  iliac  vessels. 

An  imperforate  anus  may  be  due  to  a  partial  or  complete  absence 
of  the  anal  membrane  which  separates  the  proctodeum  in  the  embryo 


302 


THE    ABDOMEN. 


from  the  hind-gut,  or  the  hind-gut  may  be  deficient  in  its  lower  part 
so  that  there  is  a  considerable  interval  between  it  and  the  skin,  or  the 
hind-gut  may  open  into  the  vagina,  uterus,  bladder,  or  the  ureters, 
when  usually  no  anus  is  evident;  or,  finally,  the  original  cloaca  condi- 
tion of  the  embryo  may  persist.  The  illustration  (see  Fig.  82)  shows 
one  of  these  conditions.  The  specimen  was  removed  at  autopsy  by 
the  author,  from  a  case  of  Dr.  L.  L.  McArthur's,  and  shows  the  hind-gut 
terminating  blindly  below,  in  a  large  pouch  which  communicated  with 
the  bladder,  so  that  intestinal  gases  escaped  through  the  urethra. 
The  communication  between  bladder  and  rectum  was  a  mere  slit  in 
the  posterior  wall  of  the  bladder.  It  should  be  one  of  the  first  duties 
of  the  obstetrician  to  examine  the  new-born  child  for  imperforate  anus. 

The  Perineal  Region  in  the  Male. 

The  perineal  region  in  the  male  lies  between  the  pubic  arch  in 
front,  the  tuberosities  of  the  ischium  laterally,  and  the  coccyx  behind 
(see  Fig.  85).  It  is  divided  into  two  regions,  the  anal  and  urogenital, 
by  a  line  drawn  between  the  two  tuberosities  of  the  ischium  (No.  8 
of  Fig.  85).  This  line  corresponds  to  the  union  of  the  deep  layer  of 
the  superficial  fascia  and  the  base  of  the  triangular  ligament;  hence, 
after  rupture  of  the  bulbous  or  membranous  urethra,  urine  can  escape 
only  as  far  back  as  the  junction  of  these  two  fasciae,  but  can  pass  forward 
to  the  anterior  wall  of  the  abdomen  and  to  the  scrotum,  causing  ab- 
scesses and  gangrene  if  the  urine  is  septic. 

At  the  center  of  the  above  transverse  line  is  the  central  point  of  the 
perineum  at  which  the  transversus  perinei,  bulbocavernosus,  levator 
ani,  and  external  sphincter  have  a  common  point  of  insertion.  It 
lies  one  inch  in  front  of  the  anus  (No.  10  in  Fig.  85).  Immediately  in 
front  of  this  central  point  lies  the  bulbous  portion  of  the  urethra  (Figs. 
83  and  85)  with  Cowper's  glands,  which  it  overlaps. 

A  stricture  of  the  urethra  is  most  frequent  in  the  bulbous  portion 
(proximal  end  of  pendulous  portion)  or  at  the  bulbo-membranous 
junction.  In  performing  external  urethrotomy  (perineal  section) 
for  stricture  or  rupture  of  the  urethra,  the  incision  is  made  in 
the  median  line  down  to  the  bulb.  The  superficial  and  deep  peri- 
neal vessels  and  nerves  can  be  best  avoided  by  keeping  in  the  median 
line.  They  are  all  branches  of  the  internal  pudic  artery  and  nerve, 
which  run  along  the  pubic  arch  and  send  vessels  and  nerves  toward 
the  median  line  (transverse  and  superficial  perineal  artery  of  the  bulb) 
(see  Fig.  85).  The  artery  of  the  bulb  is  often  unavoidably  severed, 
and  gives  rise  to  obstinate  hemorrhage. 


Fig.  85. — Surface  markings  of  male  perineum,  i,  Tuberosities  of  ischium.  2, 
Coccyx.  3,  Termination  of  Roser-Nelaton  line.  4,  Ramus  of  ischium  and  pubis.  5, 
Spongy  portion  of  urethra,  ending  at  6.  6,  Bulbous  end  of  pendulous  urethra,  the  two 
black  dots  representing  Cowper's  glands.  7,  Ischiorectal  fossa  (base  of).  8,  Line  be- 
tween two  tuberosities  of  ischium  corresponding  to  attachment  of  base  of  triangular 
ligament  and  deep  fascia.  The  transverse  perinei  muscles  lie  parallel  to  it.  9,  Margin 
of  gluteus  maximus  muscle.  The  limits  of  the  external  sphincter  are  seen  extending  from 
(2),  its  point  of  attachment,  to  (10),  central  point  of  perineum.  10,  Central  point  of 
perineum  (see  text).  P,  Left  internal  pudic  artery  giving  off  its  inferior  hemorrhoidal 
branches  just  in  front  of  P,  its  transverse  and  superficial  perineal  branches  opposite  (8); 
the  most  anterior  branch  (above  the"  figure  6)  corresponds  to  the  artery  of  the  bulb. 


303 


FEMALE    PELVIC    VISCERA. 


305 


Female  Pelvic  Viscera. 

In  the  adult  female  pelvis  the  bladder  lies  deeper  than  in  the  male, 
and,  unless  very  full,  does  not  rise  above  the  symphysis  pubis.  It  may 
prove  an  obstruction  to  the  head  during  labor,  if  not  regularly  emptied. 
It  is  pushed  down  and  forward  by  the  pregnant  uterus,  causing  a  frequent 
desire  to  urinate.  It  is  held  in  place,  as  in  the  male,  by  the  visceral 
layer  of  the  pelvic  fascia  (see  Fig.  88).  The  uterus,  under  normal 
conditions,  rests  upon  the  posterior  surface  of  the  bladder,  and  be- 
tween them  there  is  a  fold  of  peritoneum  forming  a  shallow  pouch,  the 
vesico-uterine.  The  base  of  the  bladder  is  not  separated  from  the 


Fig.  86. — Diagram  designed  to  show  the  antero-posterior  outline  of  the  pelvic  perito- 
neum in  the  mesial  pelvic  plane,  with  distended  bladder  (Ranney):  PP,  peritoneum;  R, 
rectum;  U,  uterus;  B,  bladder;  S,  symphysis  pubis.  The  vesico-abdominal,  the  vesico- 
uterine,  and  Douglas's  pouch  are  made  very  apparent. 

lower  portion  of  the  uterus  .and  upper  part  of  the  vagina  by  peritoneum, 
but  is  in  direct  contact  with  it.  Hence  fistulous  communications  may 
exist  between  the  bladder  and  the  anterior  wall  of  the  vagina  and 
cervical  canal. 

The  ureters  in  the  female  (see  Fig.  86)  pass  on  either  side,  as 
in  the  male,  from  the  brim  of  the  pelvis  along  its  lateral  wall,  between 
the  parietal  layer  of  the  pelvic  fascia  and  the  peritoneum.  The 
ureter  runs  forward  and  inward  upon  the  upper  surface  of  the 
levator  ani  and  beneath  the  base  of  the  broad  ligament  on  either 


306  THE   ABDOMEN. 

side  to  the  base  of  the  bladder.  It  crosses  below  and  behind  the 
uterine  artery  (see  Fig.  88),  passes  at  the  side  and  in  front  of  the 
cervix  uteri  and  the  lateral  fornix  of  the  vagina,  entering  the  base  of 
the  bladder  a  quarter  of  an  inch  below  the  anterior  fornix.  Its  close 
relation  to  the  cervix  renders  it  a  source  of  danger  in  operations  on  the 
lower  part  of  the  uterus,  especially  in  vaginal  hysterectomy.  If  the 
uterus  is  pulled  upward  and  forward  in  abdominal  operations,  or 
downward  and  backward  in  vaginal  operations,  the  distance  between  the 
cervix 'and  the  ureters  is  considerably  increased.  The  close  prroximity 
of  the  ureter  to  the  cervix,  and  the  fact  that  it  passes  through  the  para- 
metria,  render  it  liable  to  obstruction  in  carcinoma  of  the  uterus, 
with  infiltration  of  the  broad  ligaments,  causing  an  obstruction  to  the 
flow  of  urine  (hydro-ureter).  A  fistulous  communication  may  exist 
between  the  ureter  and  the  cervix,  or  between  it  and  the  vagina. 

Between  the  bladder  in  front  and  the  rectum  behind  lie  the  female 
reproductive  organs.  The  uterus  lies  in  the  median  line  of  the  pelvis, 
turned  slightly  to  the  right.  Its  normal  length  is  3  inches  from  cervix 
to  fundus,  but  only  2j  inches  from  the  cervix  to  the  end  of  the  uterine 
cavity.  The  latter  is  the  measurement  usually  obtained  with  a  sound. 

The  uterus  is  covered  upon  its  fundus  and  its  anterior  and  posterior 
surfaces  by  peritoneum.  Upon  the  anterior  surface  the  peritoneum  is  re- 
flected at  the  junction  of  the  cervix  and  neck  upon  the  bladder,  forming 
the  utero-vesical  fold.  Upon  its  posterior  surface  it  is  reflected  so  low 
that  it  invests  a  small  portion  of  the  posterior  fornix  of  the  vagina,  and  is 
then  reflected  upon  the  rectum,  forming  the  recto-uterine  fold.  The  fact 
that  this  posterior  pouch,  called  cul-de-sac  of  Douglas,  is  so  much 
deeper  renders  access  to  the  adnexa  (as  the  tubes  and  ovaries  are  called) 
easier  through  the  space  behind  the  cervix. 

The  uterus  is  held  in  its  normal  position  of  anteflexion  by  a  number 
of  ligaments,  but  in  spite  of  these  it  is  a  very  movable  structure,  changing 
its  position  with  the  distention  of  the  rectum  or  bladder.  One  of  the 
chief  supports  of  the  uterus,  in  addition  to  these,  is  the  muscles  of  the 
perineum,  especially  the  levator  ani  on  each  side. 

When  the  perineum  is  not  properly  repaired  after  laceration  of  the 
same,  it  permits  the  uterus  to  descend  in  the  pelvis  (prolapsus  uteri). 

The  cervix  is  held  backward  by  the  uterosacral  ligaments  and  the 
body  of  the  uterus  is  held,  under  normal  conditions,  in  a  position  of 
slight  anteflexion  through  the  attachment  of  the  round  ligaments  (see 
Figs.  86  and  87)  at  the  junction  of  the  lateral  border  and  fundus.  In 
addition  to  these  supports,  the  uterus  is  held  in  place  through  the  broad 
ligaments,  which  are  simply  wide  peritoneal  folds  passing  from  the 


Fig.  87. — View  of  kidneys  and  other  retroperitoneal  structures  and  pelvic  viscera  in 
situ  (female).  B,  Superior  surface  of  bladder.  U,  Body  of  uterus  anteflexed,  resting  upon 
bladder.  On  both  sides  are  seen  the  Fallopian  tubes  and  ovaries.  PC,  Pelvic  and  iliac 
portions  of  the  colon  (sigmoid  flexure),  lifted  up.  DC,  Descending  colon.  T,  Trans- 
versalis  muscle  and  fascia,  upon  which  outer  portion  of  kidney  rests.  Upon  the  right  side 
the  peritoneum  lining  the  posterior  wall  of  the  abdomen  has  been  removed;  upon  the  left 
side  it  covers  the  lower  pole  of  the  kidney.  The  right  kidney  is  seen  in  vertical  section,  i, 
Right  suprarenal  capsule.  2,  Pelvis  of  right  kidney.  3,  Beginning  of  ureter  (superior 
isthmus).  4,  Inferior  vena  cava,  disappearing  above  through  the  diaphragm.  5,  Ab- 
dominal aorta.  The  figure  is  placed  just  below  the  point  at  which  the  superior  mesenteric 
is  given  off.  Above  the  superior  mesenteric  artery  the  left  renal  vein  is  seen.  6,  Abdom- 
inal aorta  at  point  renal  arteries  are  given  off.  Above  the  figure  the  three  branches  of  the 
celiac  axis  can  be  seen.  7,  Placed  below  point  on  aorta  at  which  inferior  mesenteric  artery 
is  given  off.  8,  Quadratus  lumborum  muscle,  upon  which  inner  edge  of  kidney  rests.  9, 
Peritoneum  lining  iliac  fossa.  10,  Round  ligaments. 


307 


FEMALE    PELVIC    VISCERA.  309 

lateral  border  of  the  uterus  to  the  pelvic  wall.  During  pregnancy  all 
of  these  ligaments  undergo  great  hyperplasia,  and  are  apt  to  become 
relaxed  afterward,  allowing  the  uterus,  owing  to  its  greater  weight  after 
pregnancy,  to  be  displaced  in  the  pelvis. 

To  sum  up,  the  uterus  may  be  said  to  be  supported  from  above  and 
below,  the  lower  support  being  formed  by  the  perineal  body  and  the 
visceral  layer  of  the  pelvic  fascia.  The  upper  supports  are  the  round, 
broad,  and  uterosacral  ligaments.  The  uterus  is  so  movable  and  lies 
so  deep  in  the  pelvis  that  in  the  non-pregnant  condition  it  is  not  likely 
to  be  injured  by  external  violence,  such  as  a  fall  or  a  blow  upon  the 
abdomen. 

Between  the  folds  of  the  broad  ligament  is  a  loose  areolar  tissue  in 
which  lie  the  uterine  artery  and  the  vessels  supplying  the  ovary  and  tube 
(ovarian  arteries).  They  are  accompanied  in  this  parametrial  tissue, 
as  it  is  called,  by  the  uterine  and  ovarian  veins,  as  well  as  the  lymphatics 
and  nerves  which  supply  the  uterus.  This  parametrial  cellular  tissue  is 
continuous  with  the  subperitoneal  cellular  tissue  lying  between  the  visceral 
layer  of  the  pelvic  fascia  and  the  peritoneum,  being  continuous  again 
above  the  pelvic  brim  with  the  cellular  tissue  of  the  iliac  fossa,  and,  in 
fact,  with  the  subperitoneal  cellular  tissue  all  over  the  abdominal 
cavity.  Abscesses  arising  from  the  uterus,  especially  those  incident  to 
puerperal  infection,  may  migrate  through  the  lymphatics  of  the  uterine 
wall  into  this  parametrial  tissue  and  cause  abscesses  which  are  especially 
frequently  situated  behind  and  lateral  to  the  uterus,  pushing  it  forward 
and  to  the  side.  Such  pelvic  abscesses  are  best  opened  through  the 
posterior  fornix  of  the  vagina.  If  the  suppuration  spreads  in  the 
parametrial  tissue  (wrongly  called  pelvic  cellulitis),  it  may  extend  to 
the  iliac  fossa,  causing  a  bulging  above  Poupart's  ligament,  where  it  is 
necessary  at  times  to  open  it;  or  it  may  follow  along  the  retroperitoneal 
tissue  as  high  up  as  the  kidney,  dissecting  up  the  peritoneum  as  it 
advances.  Such  abscesses,  if  under  great  tension,  may  rupture  into  the 
general  peritoneal  cavity. 

Thrombosis  of  the  uterine  veins  lying  between  the  layers  of  the 
broad  ligament  is  one  of  the  most  constant  pathologic  conditions 
found  in  puerperal  sepsis. 

The  Fallopian  tubes  lie  between  the  two  layers  of  the  broad  liga- 
ments along  their  upper  margin,  opening  into  the  uterus  at  its  lateral 
angles,  or  cornua,  this  latter  portion,  called  the  uterine  portion,  is 
imbedded  in  the  substance  of  the  uterine  wall.  The  lumen  of  the  canal 
gradually  increases  in  width  as  it  passes  outward,  being  widest  close  to 
the  abdominal  opening  (ampulla),  the  narrower  portion  between  the 


310  THE    ABDOMEN. 

ampulla  and  uterine  portion  of  the  tube  being  called  the  isthmus. 
Each  tube  passes  horizontally  upward  and  outward  until  it  reaches 
the  upper  edge  of  the  ovary,  where  it  arches  backward,  descending 
along  the  posterior  border  of  the  ovary  and  resting  against  the  inner 
surface  of  the  gland  (see  Figs.  87  and  88). 

Extrauterine  pregnancy  is  most  apt  to  occur  in  the  ampulla,  the 
product  of  conception  either  being  discharged  through  the  abdominal 
ostium  (tubal  abortion),  or  the  walls  of  the  tube  rupturing,  giving  rise 
to  very  severe  hemorrhage.  When  the  abdominal  opening  of  the  tube 
is  closed  through  inflammation,  pus  or  serum  may  collect  within  the 
tube,  giving  it  a  peculiar  shape  like  that  of  a  post-horn  (pyosalpinx  or 
hydrosalpinx).  The  tube  is  about  4}  inches  in  length. 

The  ovary,  when  it  occupies  its  usual  position,  lies  with  its  long  axis 
vertical,  its  outer  surface  lying  against  the  lateral  wall  of  the  pelvis,  its 
inner  surface  looking  toward  the  pelvic  cavity.  (See  Figs.  87  and  88.) 

The  lower  pole  of  the  ovary  is  connected  with  the  lateral  angle  of 
the  uterus  by  the  ovarian  ligament.  The  ovary  lies  upon  the  posterior 
aspect  of  the  broad  ligament. 

The  blood-supply  of  the  uterus  is  received  from  the  uterine  and 
the  ovarian  arteries.  The  vessels  derived  from  these  two  sources  com- 
municate freely  with  each  other.  The  uterine  artery  lies  close  to  the 
lateral  wall  of  the  uterus  and  its  pulsations  may  be  felt  through  the  lateral 
fornices  of  the  vagina.  The  ovarian  arteries  correspond  to  the  spermatic 
arteries  of  the  male,  and  have  a  similar  origin  (see  Figs.  87  and  88). 
They  run  between  the  layers  of  the  broad  ligament  parallel  to  the  Fal- 
lopian tubes,  until  they  reach  the  lateral  wall  of  the  uterus.  That 
portion  of  the  broad  ligament  which  they  enter  is  called  the  infundibulo- 
pelvic  ligament.  The  veins  of  the  uterus  pass  into  the  internal  iliac 
veins.  The  ovarian  arteries  also  supply  the  ovaries,  the  tubes  being 
chiefly  nourished  by  a  branch  of  the  uterine  artery,  so  that  it  is  neces- 
sary, in  extirpating  the  tube  and  ovary,  to  consider  their  double  source 
of  supply  from  the  ovarian  artery  through  the  infundibulo-pelvic  liga- 
ment, which  it  is  necessary  to  ligate,  and  from  the  uterine  artery  at  the 
inner  end  of  the  tube  (Fig.  88). 

The  lymphatics  of  the  ovary  generally  arise  from  those  of  the  upper 
part  of  the  uterus,  and  end  in  the  lumbar  lymphatic  glands.  Those 
of  the  tube  also  end  in  the  lumbar  glands.  The  lymphatics  of  the 
uterus  end  for  the  most  part  in  the  lumbar  lymphatics.  Along  the 
course  of  the  round  ligament  there  are  a  few  lymphatic  vessels  which 
establish  a  relation  between  the  lymphatic  network  surrounding  the 
uterus  and  the  inguinal  glands.  The  lymphatic  glands  from  the  cervix 


Fig.  88. — Same  as  Fig.  87,  but  shows  pelvis  in  coronal  section,  i,  Suprarenal  cap- 
sule. 2,  Pelvis  of  kidney.  3,  Beginning  of  ureter.  4,  Inferior  vena  cava.  Just  above  the 
figure  4  the  renal  veins  are  given  off.  5,  Abdominal  aorta  just  below  point  at  which  supe- 
rior mesenteric  is  given  off.  6,  Abdominal  aorta  opposite  origin  of  renal  arteries.  Above 
it  the  three  branches  of  the  celiac  axis  can  be  seen.  7,  Abdominal  aorta,  just  below  point 
of  origin  of  inferior  mesenteric.  8,  Quadratus  lumborum  upon  which  kidney  lies.  9, 
Peritoneum  lining  iliac  fossa.  Beneath  the  figure  the  iliopsoas  muscle  can  be  seen,  the 
white  dot  representing  the  anterior  crural  nerve.  10,  Peritoneum  of  iliac  fossa  continued 
so  as  to  form  pelvic  peritoneum.  Below  the  figure  10  the  external  iliac  artery  and  vein  are 
seen,  n,  Internal  and  external  arcuate  ligaments  of  diaphragm.  12,  Ureter,  lying  one 
inch  to  right  and  left  sides,  respectively,  of  cervix  uteri.  13,  Uterovesical  pouch  (cul-de-sac 
of  Douglas),  at  its  lateral  edge.  Below  the  figure  the  left  ovary  and  tube  are  seen  in  situ. 
The  uterus  and  adnexa  are  at  a  higher  level  than  normal  (level  of  inlet),  on  account  of  the 
pregnant  uterus.  14,  Levator  ani.  The  parametric  space  is  exaggerated  in  size,  on  ac- 
count of  the  high  position  of  the  uterus.  15,  Ischiorectal  space.  16,  Obturator  internus, 
lying  between  the  parietal  layer  of  pelvic  fascia  and  the  lateral  walls  of  the  pelvis.  The 
white  spot  to  the  inner  side  of  16  corresponds  to  the  level  of  the  white  line,  from  which  the 
levator  ani  arises,  and  at  this  point  the  visceral  layer  of  the  pelvic  fascia  passes  inward, 
above  the  ischiorectal  fossa.  U,  Fundus  of  uterus.  The  uterine  cavity  is  seen  distended 
by  a  fetus  and  membranes.  CC,  Cervical  portion  of  uterus  (cervix  uteri);  between  the  two 
letters  the  cervical  canal  lies,  with  narrow  internal  os  and  wider  external  os.  V,  Walls  of 
vagina.  PC,  Pelvic  and  iliac  portions  of  colon  turned  upward  (sigmoid  flexure).  DC,  De- 
scending colon,  lying  upon  posterior  wall  of  abdomen  and  crossing  lower  pole  of  left  kidney. 
T,  Transversalis  muscle.  Above  the  ureter  (12)  the  uterine  artery  is  seen  on  each  side. 


Fig.  89. — View  of  external  genitalia  of  female,  and  cross-section  of  upper  third  of  thigh, 
i,  Labia  majora.  2,  Labia  minora.  3,  Perineum.  4,  Anus.  5,  Internal  saphenous  vein. 
6,  Femoral  vein.  7,  Femoral  artery.  8,  Anterior  crural  nerve.  Upon  the  left  side  of  the 
body  the  black  area  below  7  indicates  the  profunda  femoris.  9,  Adductor  longus  muscle. 
10,  Adductor  magnus.  n,  Sartorius.  12  and  13,  Vastus  externus  and  internus.  14, 
Biceps.  15,  Semimembranosus.  16,  Semitendinosus.  S,  Sciatic  nerve.  P,  Pectineus 
muscle.  R,  Rectus  femoris.  F,  Shaft  of  femur. 


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315 


FEMALE    PELVIC    VISCERA.  317 

uteri  end  toward  the  bifurcation  of  the  common  iliac  artery.  Carcinoma 
of  the  cervix  is  far  more  frequent  than  that  of  the  body  of  the  uterus, 
and  its  transmission  occurs  through  the  lymphatics  lying  in  the  para- 
metria  on  either  side  of  the  uterus  toward  the  lumbar  glands. 

The  uterine  canal  opens  into  the  vagina,  the  angle  between  the  axes 
of  the  two  being  a  little  greater  than  a  right  angle.  That  portion  of 
the  cervix  which  projects  into  the  vagina  is  called  the  vaginal  portion. 
Its  outer  aspect  is  covered  with  pavement  epithelium  which  is  continu- 
ous with  that  of  the  vagina;  but  where  the  cervical  canal  begins,  it 
becomes  cylindrical  in  character,  and  this  point  of  transition  is  a  frequent 
starting-point  of  carcinoma,  as  are  also  the  many  mucous  glands  lining 
the  cervical  canal  close  to  the  external  os.  Carcinoma  of  the  cervix  is 
far  more  frequent  than  is  carcinoma  of  the  body  of  the  uterus. 

In  making  a  vaginal  examination,  one  feels  the  vaginal  portion  of 
the  cervix,  the  os  being  felt  as  a  small  transverse  slit  in  nulliparae. 
Above  and  behind  the  cervix  is  the  posterior  fornix  of  the  vagina, 
which  is  in  close  proximity  to  the  recto-uterine  pouch,  or  pouch  of 
Douglas.  In  front  of  the  cervix  is  the  more  shallow  anterior  fornix, 
while  lying  in  front  of  the  anterior  vaginal  wall  the  urethra  can  be  de- 
tected as  a  cylindrical  cord-like  thickening.  Lateral  to  the  cervix  can 
be  felt  the  lower  part  of  the  broad  ligament  and  the  pulsations  of  the 
uterine  artery,  on  each  side. 

The  rectum  in  the  female  is  in  contact  above  with  the  pouch  of 
Douglas  and  below  with  the  vagina;  lateral  to  it,  the  ischiorectal  fossae 
exist,  as  in  the  male  (Fig.  88). 

Abscesses  in  the  pouch  of  Douglas  not  infrequently  rupture  into  the 
rectum. 

The  external  genitalia  in  the  female  (see  Fig.  89)  include  the  labia 
majora  and  the  labia  minora,  between  which  is  the  opening  of  the 
vagina.  At  their  point  of  junction  is  the  clitoris,  and  between  it  and 
the  opening,  or  introitus  vagina,  is  the  external  orifice  of  the  urethra, 
the  urethral  canal  in  the  female  being  short — only  ij  inches  long. 

The  pelvic  viscera  in  the' female  are  supported  by  the  pelvic  fascia, 
which  is  the  same  as  in  the  male.  (See  description  of  the  Pelvis  in 
General.)  The  pelvic  diaphragm  is  composed  of  the  levator  ani  and 
coccygeal  muscles,  which  form,  in  addition  to  the  pelvic  fascia,  a  strong 
support  for  the  uterus,  bladder,  and  rectum.  This  pelvic  diaphragm  pulls 
the  vagina  upward  during  childbirth,  pushing  the  child's  head  forward 
so  as  to  cause  it  to  rotate  under  the  pubic  arch.  The  pelvic  floor  is 
also  made  up  of  the  perineal  fascia  and  muscles,  and  the  perineal  body, 
which  is  the  name  given  to  the  tissue  between  the  rectum  and  vagina. 


^1 8  THE    ABDOMEN. 

Of  all  of  these  structures,  the  levatores  ani  and  the  perineal  body  con- 
tribute the  chief  support  from  below. 

The  perineal  body  is  composed  of  the  posterior  ends  of  the  bulbo 
cavernosus  muscles,  fibers  belonging  to  the  superficial  transversus 
pcrinei,  the  internal  and  external  sphincter  ani,  and  the  levator  ani 
muscles.  It  corresponds  in  a  way  to  the  central  point  of  the  peri- 
neum in  the  male,  where  the  muscles,  fasciae,  and  ligaments  meet. 
These  structures  all  being  attached  to  the  surrounding  bones,  the  peri- 
neal body  becomes  the  chief  support  of  the  whole  pelvic  floor.  When 
it  is  torn,  the  vagina,  rectum,  and  uterus  lose  one  of  their  chief  supports 
and  are  apt  to  prolapse.  During  childbirth  the  perineal  body  forms 
a  strong  barrier,  against  which  the  child  is  pressed.  It  resists  so  firmly 
that  it  is  frequently  so  stretched  as  to  be  little  more  than  the  thickness 
of  paper. 

Nerves  of  the  Abdominal  Cavity. 

The  nerves  which  supply  the  abdominal  viscera,  the  diaphragm,  and 
the  muscles  of  the  abdominal  wall  are  all  in  close  relation  to  each  other. 
They  belong  to  the  cerebrospinal  and  sympathetic  systems,  but  com- 
municate with  each  other  by  many  branches ;  so  that  lesions  of  the  viscera 
are  often  referred,  as  was  explained  on  page  220,  to  the  corresponding 
point  (on  the  skin)  of  distribution  of  the  spinal  segment  which  communi- 
cates with  it.  The  fact  that  the  skin  and  muscles  of  the  abdomen  are 
supplied  by  branches  of  the  last  dorsal  and  lumbar  nerves,  and  that  these 
nerves  have  many  anastomoses  with  the  sympathetic,  is  also  of  great  im- 
portance. On  the  one  hand,  inflammation  of  the  viscera  causes  reflex 
contraction  of  the  abdominal  muscles  and  extreme  sensitiveness  of  the 
corresponding  area  of  skin,  thus  acting  as  a  splint  for  the  inflamed  viscus. 
Irritations  of  the  skin — for  example,  a  blow  upon  the  abdomen,  or 
burns — are  followed  by  a  reflex  contraction  of  the  abdominal  muscles, 
unless,  as  often  happens,  the  blow  is  so  sudden  as  not  to  permit  of  this 
protection  on  the  part  of  the  muscles.  The  two  vagi  nerves,  after  pene- 
trating the  diaphragm,  supply  the  lower  end  of  the  esophagus  and  the 
entire  stomach.  The  right  vagus  (see  Fig.  91)  enters  the  abdominal  cavity 
with  the  esophagus,  and  is  distributed  to  the  posterior  surface  of  the 
stomach.  It  forms  the  posterior  gastric  plexus,  and  sends  communicating 
branches  to  the  celiac,  splenic,  and  renal  plexuses.  The  left  vagus  is  dis- 
tributed upon  the  anterior  surface  of  the  stomach,  forming  the  anterior 
gastric  plexus,  and  sends  communicating  branches  to  the  hepatic  plexuses 
of  the  sympathetic.  The  two  phrenic  nerves  are  distributed  chiefly  to 
the  inferior  surface  of  the  diaphragm  (subperitoneal  branches).  Both 


6th  Intercostal 


yth  Intercostal 


Coccygeal 
plexus 


Left  vagus 
Right  vagus 
Solar  plexus 


_  Sup.  mesenteric 
plexus 

Renal  plexus 
•-  Spermatic  plexus 

Aortic  plexus 


Inferior  mesen- 
teric plexus 


HI Aortic  plexus 


Right  pelvic 

plexus 

Superior  hemor- 
rhoidal  plexus 


Rectal  and  vesi- 
cal  plexuses 


Fig.    91. — Nerve-supply   of   abdominal   viscera   and   relations   of   spinal    nerves  to  sym- 
pathetic (after  Quain). 


319 


NERVES    OF    THE    ABDOMINAL    CAVITY.  321 

nerves  communicate  with  the  solar  plexus  of  the  sympathetic.  This  latter 
communication  explains  the  fixation  of  the  diaphragm  in  inflammatory 
conditions  of  the  peritoneum  or  of  the  viscera  of  the  abdominal  cavity,  as 
well  as  the  dyspnea  due  to  both  mechanical  and  nerve  interference  with 
the  action  of  the  diaphragm  in  septic  peritonitis.  It  will  also  explain 
why  a  diaphragmatic  pleurisy  or  a  subdiaphragmatic  peritonitis  will  often 
give  rise  to  the  symptoms  of  severe  intestinal  lesions. 

The  abdominal  sympathetic  can  be  divided  into  a  middle  and  two 
lateral  portions.  The  middle  consists  of  a  number  of  plexuses  (see  Fig. 
91)  which  communicate  with  the  lateral  cords  (see  below).  The  most 
important  of  these  plexuses  are  the  solar,  the  superior  mesenteric,  the 
renal,  the  aortic,  the  inferior  mesenteric,  the  spermatic,  the  right  pelvic, 
the  hemorrhoidal,  the  rectal,  and  the  vesical  plexuses.  'These  plexuses 
are  made  up  to  a  great  extent  of  branches  received  from  the  lateral 
cords  of  the  sympathetic  (especially  the  upper  plexuses),  the  great  and 
small  splanchnic  nerves  penetrating  the  diaphragm  (see  Fig.  91)  at  its 
center,  and  connecting  with  each  other  to  form  the  celiac  axis.  All  of  the 
portions  of  the  abdominal  sympathetic,  especially  the  upper,  are  in  direct 
communication  with  the  spinal  cord  (see  Fig.  91)  through  the  rami  com- 
municantes. 


^22  UPPER    EXTREMITY. 


UPPER  EXTREMITY. 

Examination  of  the  Shoulder  and  Upper  Extremity  in  the  Liv- 
ing.— i.  Note  that  the  shoulder  has  a  convex  outline  dependent  on  the 
development  of  the  deltoid  muscle  and  the  underlying  head  of  the 
humerus.  If  the  muscle  is  atrophied,  or  the  head  be  absent,  as  in  dislo- 
cation, there  is  a  concavity  present  below  the  acromion  process  (see 
Fig.  92). 

2.  The  deltoid  hangs  like  a  curtain  from  the  outer  end  of  the  clavicle 
and  acromion,  covering  the  humerus.     Palpate  it  to  its  insertion  at  the 
deltoid  tubercle  on  the  outer  side  of  the  humerus. 

3.  The  clavicle  can  be  felt  in  its  entire  length.     Note  the  junction  of 
its  two  curves  (middle  third),  where  the  bone  most  frequently  breaks. 
The  prominent  sternoclavicular  joint  at  the  inner  end  of  the  clavicle,  and 
the  acromioclavicular  at  its  outer  end,  can  be  readily  palpated. 

4.  The  exact  relation  of  the  outer  end  of  the  clavicle  to  the  acromion 
must  be  noted.     The  groove  between  them  runs  in  an  antero-posterior 
direction.     Motion  at  this  joint  is  at  times  mistaken  for  a  fracture, 
especially  in  children. 

5.  The  greater  part  of  the  spine  of  the  scapula  and  acromion  can  be 
felt  subcutaneously.     The  outer  border  of  the  acromion  is    used    in 
measuring  the  arm  (see  Fig.  93). 

6.  Just  beneath  the  deltoid  the  tuberosities  of  the  humerus  are  to  be 
palpated. 

7.  Place.the  fingers  high  up  in  the  axilla  and  the  head  of  the  humerus 
can  be  felt  in  the  glenoid  cavity,  extending  beyond  the  edges  of  the  same. 

8.  Observe  the  movements  of  the  head  of  the  humerus  by  placing  the 
thumb  in  front  and  the  fingers  behind  the  deltoid  muscle,  and  rotate  the 
arm  with  elbow  flexed.     The  head  faces  in  the  direction  of  the  internal 
condyle. 

9.  Just  below  the  outer  end  of  the  clavicle  is  a  groove  indicating  the 
point  where  the  thorax  is  separated  from  the  shoulder.     In  this  groove 
(infraclavicular   fossa,   or   Mohrenheim's  groove),   about    two   finger- 
breadths  below  the  clavicle,  the  coracoid  process  can  be  felt.     Below  the 
groove  is  the  pectoralis  major,  above  it  the  deltoid.     In  subcoracoid  dis- 
location of  the  humerus  (Fig.  92)  the  head  of  the  bone  can  be  felt  in  this 
groove.     In  the  groove  lie  the  cephalic  vein  and  a  branch  of  the  acromio- 
thoracic  artery  superficially,  and  the  axillary  vessels  and  brachial  plexus 
at  a  deeper  level  (see  Fig.  94). 


Fig.  92. — Subcoracoid  dislocation  of  the  humerus  (modified  from  Helferich  and 
Hoffa),  showing  how  the  head  may  press  upon  the  brachial  plexus  and  vessels,  and  also 
showing  the  change  in  the  axis  of  the  arm  as  a  result  of  this  dislocation,  and  the  apparent 
lengthening  of  the  arm,  as  measured  from  the  acromion  process  to  the  external  condyle. 


323 


Fig-  93- — Line  of  measurement  of  arm.  The  measurement  is  made  along  the  line 
i,  from  the  acromion  process,  AcPr.,  to  external  condyle  (Ex.  Cond.).  Clavicle  (Cl), 
showing  the  joint  between  the  acromion  process  and  clavicle. 


325 


Brachial  plexus 

Cephalic  vein 
Acromiothoracic 
artery 


Pectoral  is  major 
insertion 


Coracobrach  ialis 


Musculocutaneous 
nerve 


Brachial  artery  and 
veins 


Brachialis  anticus 
Median  nerve 


—  Pectoralis  minor 


Serratus  anticus 

Long  thoracic  ar- 
tery, vein,  and 
nerve 

Internal  cutaneous 
nerve 

Latissimus  dorsi 


Posterior  circum- 
flex nerve 
Middle  cutaneous 
nerve 


Musculospiral 
nerve 


Triceps 


Inferior    ulnar  col- 
lateral artery 


Ulnar  nerve 


Fig.  94. — Dissection  of  brachial  region  (Henle). 


327 


Fig.  95. — Movements  of  joints  of  upper  extremity.  Maximum  flexion  of  elbow  (i) 
and  of  wrist-joint  (2),  and  maximum  extension  of  elbow  (3)  and  wrist-joint  (4).  5  and  6, 
Best  points  to  measure  circumferences  of  forearm  and  arm. 


329 


Fig.  96. — Surface  markings  of  principal  blood-vessels  and  nerves  of  arm  and  of 
tendon-sheaths  of  hand,  i,  Axillary  artery.  2,  Musculospiral  nerve,  shown  in  double 
outline,  indicating  its  course  on  the  back  of  the  arm,  its  continuation  as  the  radial  nerve 
being  shown  in  the  single  outline.  3,  Brachial  artery.  4,  Radial  artery.  5,  Ulnar 
artery.  6.  Median  nerve.  7,  Ulnar  nerve.  In  the  hand  the  flexor  tendon-sheaths  are 
seen  in  the  following  relations:  That  of  the  thumb  communicates  with  the  common  flexor 
sheaths  under  the  annular  ligament;  that  of  the  little  finger  extends  to  this  common  sac 
and  often  communicates  with  it;  the  distal  set  of  the  index,  middle,  and  ring  fingers  extends 
from  the  middle  of  the  hand  to  the  middle  of  the  last  phalanx,  the  proximal  is  shown  at 
the  wrist. 


331 


EXAMINATION   OF   THE   ARM   IN   THE   LIVING.  333 

10.  Palpate  the  anterior  and  posterior  walls  of  the  axilla,  formed  by 
the  pectoralis  major  and  latissimus  dorsi  respectively. 

11.  Observe  the  movements  of  the  shoulder-joint.     They  are  (a) 
abduction  (raising  arm  away  from  side  of  body)  (see  Fig.  95).     Abduc- 
tion is  carried  out  principally  through  the  action  of  the  deltoid  and  supra- 
spinatus  muscles,     (b)  Adduction  (bringing  arm  toward  median  line  of 
body),  executed  by  action  of  teres  major  and  minor,  pectoralis  major,  and 
latissimus  dorsi;  (c)  flexion  (raising  the  arm  in  anterior  and  posterior 
direction  forward) ;  (d)  raising  arm  backward,  upward,  and  inward— 
(e)  rotation  and  circumduction. 

12.  Passing  downward  from  the  acromion  to  the  arm  is  the  bicipital 
groove,  and  running  down  to  the  upper  end  of  the  radius,  where  it  is  in- 
serted by  a  firm  tendon,  the  biceps  muscle  can  be  felt.     On  either  side  of 
the  biceps  there  is  a  depression  or  groove  (internal  and  external  bicipital 
grooves).     On  the  inner  side  is  the  coracobrachialis. 

13.  Between  this  latter  muscle  and  the  biceps  the  brachial  artery  and 
some  of  the  branches  (median  and  ulnar)  of  the  brachial  plexus  can  be 
felt  in  the  inner  groove,  and  the  basilic  vein  seen  in  the  skin  passing  up- 
ward (see  Figs.  94  and  96). 

14.  On  the  outer  side  of  the  biceps  the  cephalic  vein  is  seen.     The 
round  outline  of  the  humerus  can  be  felt  on  both  sides  of  the  biceps. 

15.  In  thin  individuals  one  can  feel  the  musculospiral  (Fig.  97)  nerve 
in  its  groove  on  the  outer  side  of  the  biceps,  at  the  middle  third  of  the 
bone  (just  below  the  insertion  of  the  deltoid). 

1 6.  Along  the  posterior  aspect  of  the  arm  the  triceps  muscle  is  felt, 
attached  by  its  tendon  below  into  the  olecranon  process. 

17.  Note  the  movements  of  the  elbow- joint;  they  are  flexion  and  ex- 
tension, the  former  being  carried  out  principally  by  the  biceps,  the  latter 
by  the  triceps. 

1 8.  At  the  front  of  the  elbow,  by  compressing  the  arm  above  so  as  to 
obstruct  the  return  flow,  the  veins  lying  subcutaneously  in  front  of  the 
joint  can  be  readily  distinguished.     The  median  vein  is  seen  to  divide 
into  an  outer  or  median  cephalic,  and  an  inner  or  median  basilic  vein 
(see  Figs.  99  and  100).     The  former  joins  over  the  external  condyle  with 
the  radial  to  form  the  cephalic,  the  latter  (median  basilic)  joins  with  the 
ulnar  to  form  the  basilic. 

19.  On  either  side  of  the  biceps  tendon  there  is  a  muscular  elevation. 
On  the  outer  it  corresponds  to  the  supinator  longus  and  common  ex- 
tensor mass;  on  the  inner,  to  the  pronator  radii  teres  and  common  set  of 
flexors.     Between  the  latter  and  the  biceps  tendon  there  is  a  groove  in 
which   the  termination   of  the  brachial  artery    is   palpable  and   the 


334  UPPER    EXTREMITY. 

median  nerve  can  be  felt  as  a  firm  cord.  On  deep  pressure  the  rotary 
movements  of  the  head  of  the  radius  can  be  felt,  just  external  to  the 
supinator  longus,  when  the  forearm  is  pronated  and  supinated  alter- 
nately. 

20.  At  the  back  of  the  elbow  the  two  condyles  of  the  humerus  and  the 
olccranon  process  of  the  ulna  can  be  readily  felt.     When  the  arm  is  ex- 
tended, the  tip  of  the  olecranon  is  in  a  straight  line  with  the  two  condyles 
(see  Fig.  98).     When  the  arm  is  flexed  at  a  right  angle,  these  three  points 
will  not  be  found  in  the  same  line,  the  olecranon  tip  is  then  about  \ 
inch  (i  cm.)  lower  than  the  two  condyles.    This  relation,  as  will  be  seen 
later,  is  of  great  value  in  the  diagnosis  of  injuries  in  the  vicinity  of  the 
elbow.     Between  the  internal  condyle  and  the  olecranon  there  is  a  de- 
pression in  which  the  ulnar  nerve  lies. 

21.  The  supinated  forearm  frequently  forms  with  the  upper  arm  an 
angle  known  as  the  carrying  angle  (see  Fig.  51).      It  varies  normally 
within  very  wide  limits. 

22.  On  the  anterior  surface  of  the  forearm  the  two  muscular  prom- 
inences, above  described  as  lying  on  either  side  of  the  biceps  tendon, 
gradually  converge  in  the  upper  third  of  the  forearm  into  one  muscular 
mass,  from  which  various  tendons  can  be  seen  to  arise. 

23.  When  the  hand  is  flexed  upon  the  forearm  several  prominent 
tendons  can  be  distinguished  just  above  the  wrist.     Most  externally  is 
that  of  the  flexor  carpi  radialis;  most  internally,  that  of  the  flexor  carpi 
ulnaris;  and  between   these,  those  of    the  flexor  sublimis  digitorum. 
Occasionally  the  median  nerve  can   be  felt  on  the  inner  side  of  the 
flexor  carpi  radialis  tendon.    Upon  its  outer  side  the  radial  artery  can  be 
felt.     The  ulnar  artery  lies  on  the  outer  side  of  the  flexor  carpi  ulnaris 
tendon  (see  Fig.  101). 

24.  The  radius  can  be  felt  upon  the  anterior  aspect  of  the  forearm,  in 
its  lower  two-thirds;  the  ulna  can  be  felt  only  indistinctly,  except  in  its 
lower  third  on  the  anterior,  but  along  its  entire  length  upon  the  posterior 
aspect. 

25.  Just  distal  to  the  lower  end  of  the  radius  (in  front)  the  prominent 
scaphoid  bone  can  be  felt.     The  depression  upon  its  inner  or  ulnar  side 
corresponds  to  the  wrist-joint.     The  hypothenar  eminence  passes  dis- 
tally  from  the  inner  side  of  this  depression,  the  thenar  from  its  outer. 
These  are  the  muscular  ridges  which  form  the  boundaries  of  the  palm  of 
the  hand.     When  the  fingers  are  flexed,  prominences  can  be  felt  in  the 
palm,  due  to  the  flexor  tendons.     When  the  hand  is  supine,  creases 
which  form  an  irregular  letter  M  can  be  seen  in  the  palm,  with  base  to- 
ward the  ulnar  side;  the  distal  portion  marks  the  proximal  termination  of 


Fig-  97- — Relations  of  posterior  circumflex  and  musculospiral  nerves  to  surgical 
neck  and  shaft  of  humerus.  i,  Coracoid  process.  2,  Posterior  circumflex  nerve,  shown 
in  dotted  line  as  it  winds  around  the  posterior  aspect  of  the  surgical  neck  of  the  humerus 
(H).  3,  Musculospiral  nerve,  shown  in  dotted  outline  as  it  curves  around  the  posterior 
aspect  of  the  middle  third  of  the  humerus  in  the  musculospiral  groove. 


335 


Fig.  98. — Surface  markings  of  the  principal  nerves  of  the  arm,  as  seen  from  the  pos- 
terior aspect,  and  relation  of  the  anatomic  points  at  the  elbow,  i,  Posterior  circumflex 
nerve,  as  it  winds  around  the  surgical  neck  of  the  humerus.  2,  Musculospiral  nerve,  as 
it  winds  around  the  posterior  aspect  of  the  shaft  of  the  humerus.  3,  Ulnar  nerve,  pro- 
jected on  the  posterior  aspect  of  the.  arm,  which  it  reaches  to  pass  between  6  and  7,  internal 
condyle  and  olecranon  process.  4,  Line  joining  two  condyles.  5,  External  condyle.  6, 
Internal  condyle.  7,  Olecranon  process.  When  arm  is  extended  these  three  points  are 
in  a  straight  line,  as  seen  on  the  right  side.  When  arm  is  flexed,  as  on  the  left,  they  form 
an  angle,  the  olecranon  process  lying  below  a  line  (4)  joining  the  external  and  internal 
condyles.  8,  Position  of  olecranon  bursa.  9,  Relation  of  head  of  radius  to  outer  condyle. 


337 


Flexor  carp 

Flexor  subl.  digit.  ..^f 
Dinar  artery 
Ulnar  nerve  _ 

Flexor  carpi  ulnaris-.- 

Flexor  profundus  digi- 
torum 


Median  nerve 
Radial  artery 
Radial  nerve 

Supin.  longus 
— Supin.  brevis 


Ext.  carpi  radialis 
Posterior  interosseous  nerve 


Extensor  carpi  ulnaris 


Extens.  carpi  ulnaris 
Extens.  comm.  digit. 


Fig.  99. — Cross-section  at  middle  of  left  forearm;  also  showing  veins  at  bend  of  elbow. 
U,  Ulnar  vein;  M,  Median  vein;  R,  Radial  vein;  MC,  Median  cephalic  vein;  MB,  Median 
basilic  vein;  B,  Basilic  vein;  C,  Cephalic  vein. 


339 


Fig.  100. — Surface  markings  of  principal  veins  on  anterior  surface  of  body,  i,  Ante- 
rior intercostal  veins,  which  arise  from  the  internal  mammary.  2,  Continuation  of  the 
anterior  intercostal  veins,  which  join  with  the  posterior  intercostals,  having  their  origin  in 
the  azygos  veins.  3,  Terminal  branches  of  internal  mammary,  forming  the  superior 
epigastric  veins.  4,  Superficial  inferior  epigastric  vein.  5,  Deep  inferior  epigastric  vein. 
6,  External  iliac  veins.  7,  Femoral  vein.  The  dotted  portion  below  shows  the  popliteal 
vein  as  projected  on  the  anterior  surface  of  the  thigh.  8,  Internal  saphenous  vein,  empty- 
ing into  the  femoral  vein  at  the  saphenous  opening.  9,  Cephalic  vein,  joining  with  10, 
the  basilic  vein,  to  empty  into  the  subclavian.  n,  Median  basilic  vein,  which  is  most 
often  chosen  for  intravenous  transfusion  or  venesection.  12,  Median  cephalic  vein. 
R,  Radial  vein.  M,  Median  vein.  U,  Ulnar  vein. 


«  Hlxt.  carpi  rad. 

brevior  et 
Radialis 
longior 


Fig.   101. — Cross-section  just  above  wrist. 


343 


Fig.  102. — Epiphyses  in  boy,  aged  six.  i,  Upper  epiphysis  of  humerus.  2,  Shaft 
of  humerus.  3,  Lower  epiphysis  'of  humerus.  4,  Upper  epiphysis  of  ulna.  5,  Shaft 
of  ulna.  6,  Lower  epiphysis  of  ulna.  8,  Shaft  of  radius,  above  which  is  the  upper  epi- 
physis. 9,  Lower  epiphysis  of  radius.  10,  Anterior  superior  spine  of  ilium,  n,  Head 
of  femur,  showing  epiphyseal  line  joining  it  to  the  neck.  12,  Greater  trochanteric  epi- 
physis. 13,  Shaft  of  femur.  14,  Lower  epiphysis  of  femur.  15,  Upper  epiphysis  of 
tibia.  1 6,  Shaft  of  tibia.  18,  Lower  epiphyses  of  tibia  and  fibula.  19,  Shaft  of  fibula, 
above  which  is  the  upper  epiphysis  of  the  fibula. 


345 


SURFACE    MARKINGS.  347 

the  flexor  tendon-sheaths  for  the  fingers  (see  Fig.  96).  Inside  of  the 
creases  forming  this  letter  M  lies  the  greater  portion  of  the  superficial 
palmar  arch  and  the  terminations  of  the  proximal  and  distal  set  of 
flexor  tendon-sheaths. 

26.  Along  the  middle  of  the  back  of  the  forearm  is  seen  a  muscular 
prominence  formed  by  the  extensor  communis  digitorum,  whose  tendons 
become  prominent  over  the  back  of  the  hand  when  the  fingers  are  ex- 
tended.    The  groove  to  its  inner  side  corresponds  to  the  posterior  border 
of  the  ulna.     When  the  thumb  is  extended,  a  prominence  is  seen  running 
obliquely  across  the  lower  third  of  the  radius.     It  is  formed  by  the  ex- 
tensors of  the  thumb.     Between  two  of  these  (seen  when  thumb  is 
forcibly  extended)  is  the  tabatiere,  or  depression  known  as  the  "French- 
man's snuff-box."     In  it  the  radial  artery  lies  as  it  passes  across  the  back 
of  the  metacarpal  bone  of  the  thumb. 

27.  The  shafts  and  heads  of  the  metacarpal  bones,  especially  those  of 
the  thumb,  can  be  distinctly  felt  on  the  dorsum  of  the  hand.     Along  the 
back  of  each  bone  can  be  felt  the  corresponding  extensor  tendon  when 
the  fingers  are  extended. 

28.  Where  the  hand  and  forearm  meet,  there  is  a  distinct  depression 
on  the  dorsum,  corresponding  to  the  wrist-joint.     When  the  fingers  are 
fully  flexed,  the  gap  corresponding  to  the  metacarpophalangeal  joint  can 
be  felt  just  distal  to  the  head  of  each  metacarpal  bone.    Between  the  first 
and  second  metacarpal  bones  is  seen  the  prominent  first  interosseous 
muscle.     The  extensor  tendons  cannot  be  felt  along  the  back  of  the 
fingers.    The  interphalangeal  joints  are  best  examined  when  the  fingers 
are  alternately  flexed  and  extended.    The  surface  veins  are  very  distinct 
on  the  dorsum  of  the  hand. 

29.  Observe  the  movements  of  the  wrist-joint  (see  Fig.  95).     They 
consist  of  flexion  and  extension.     Note  the  movements  of  the  fingers — 
flexion  and  extension,  abduction  and  adduction.    In  addition,  the  thumb 
has  the  power  of  circumduction.     Note  the  action  of  the  interossei  and 
lumbricales.     They  cause  flexion  at  the  metacarpophalangeal  articula- 
tion.     The  flexor  sublimis  and  profundus  together  flex  the  proximal 
interphalangeal  joint.     The  flexor  profundus  alone  acts  on  the  last  or 
second  phalangeal  joint. 

30.  Mark  on  the  surface  of  the  body  (see  Fig.  102)  the  position  of 
the  epiphyseal  cartilages  of  the  humerus,  radius,  and  ulna. 

Surface  Markings. 

i.  The  course  of  the  axillary  artery  when  the  arm  is  raised  from  the 
side  (abducted)  is  represented  by  a  line  drawn  from  about  the  middle  of 


348  UPPER    EXTREMITY. 

the  clavicle  to  the  inner  side  of  the  coracobrachialis  (junction  of  anterior 
and  middle  thirds  of  axilla).    (See  Fig.  96.) 

2.  The  axillary  vein  corresponds  to  the  above  (in  the  same  position 
of  the  arm),  but  lies  in  front  of  the  artery.     When  the  arm  hangs  at  the 
side,  the  vein  lies  on  the  inner  side  of  the  artery  (see  Figs.  94  and  96). 

3.  The  brachial  artery  corresponds  to  a  line  drawn  along  the  inner 
border  of  the  biceps  from  the  termination  of  the  axillary  artery  to  the 
bend  of  the  elbow;  a  line  from  the  latter  point  to  the  scaphoid  bone 
represents  the  radial  artery ;  one  to  the  pisiform  bone,  the  course  of  the 
ulnar  artery  (see  Fig.  96). 

4.  The  posterior  circumflex  nerve  and  artery  lie  about  a  finger's- 
breadth  above  the  center  of  the  vertical  axis  of  the  deltoid  muscle  (see 

Fig-  97)- 

5.  The  median  nerve  corresponds  in  the  upper  arm,  as  far  as  the 
bend  of  the  elbow,  to  the  course  of  the  brachial  artery,  i.  e.,  along  inner 
border  of  biceps ;  from  this  point  down  to  the  hand  it  follows  closely  the 
median  line  of  the  forearm. 

6.  The  course  of  the  ulnar  nerve  corresponds  to  a  line  drawn  from 
the  apex  of  the  axilla  to  the  internal  condyle,  and  from  this  point  along  the 
ulnar  side  of  the  arm  to  the  wrist  on  the  radial  side  of  the  flexor  carpi 
ulnaris  tendon. 

7.  The  course  of  the  musculospiral  nerve  corresponds  to  a  line 
drawn  from  the  axilla  obliquely  around  the  back  of  the  upper  arm  to  the 
external  condyle  (point  of  division  of  the  nerve).     This  line  crosses  the 
humerus  at  the  junction  of  its  lower  and  middle  thirds  (Figs.  97  and  98). 

The  Shoulder  Region. 

This  comprises  the  clavicle,  scapula,  upper  end  of  the  humerus, 
shoulder-joint,  axilla,  and  soft  parts  covering  them.  The  skin  is  of 
medium  thickness  except  over  the  clavicle,  where  it  is  very  thin  and 
elastic.  In  the  subcutaneous  tissue  lie  the  terminal  branches  of  the 
superficial  cervical  plexus  (Fig.  103).  Beneath  the  clavicle  lie  the  sub- 
clavian  artery  and  vein  upon  the  first  rib,  the  vein  in  front.  The  main 
trunks  of  the  brachial  plexus  and  the  vessels  are  "separated  from  the 
clavicle  by  the  thick  subclavius  muscle,  which  protects  them  from  injury 
in  fractures  of  the  clavicle. 

Fractures  of  the  Clavicle. — The  clavicle  is  more  frequently  broken 
than  any  other  bone,  on  account  of  its  exposed  position.  The  most  fre- 
quent seat  is  at  the  middle  third  of  the  bone,  where  the  two  curves  meet. 
The  inner  fragment  is  pulled  up  by  the  sternocleidomastoid,  the  outer 
forward  by  the  pectoralis  major  and  the  weight  of  the  limb  (see  Fig. 


Fig.  103. — Anterior  view  of  the  areas  of  distribution  of  the  sensory  nerves  of  the  skin  (shown  on 
the  left  side  of  the  body),  and  distribution  of  sensation  according  to  segments  of  the  spinal  cord 
(shown  on  the  right  side  of  the  body),  i,  Ophthalmic  nerve.  2,  Superior  maxillary  nerve.  3,  In- 
ferior maxillary  nerve.  The  points  of  exit  of  the  supra-orbital,  infra-orbital,  and  mental  nerves  are 
shown  by  the  markings  X.  4,  Points  of  exit  of  the  anterior  intercostal  branches  of  the  intercostal 
nerves.  5,  Points  of  exit  of  the  lateral  branches  of  the  intercostal  nerves.  6,  Intercosto-humeral 
nerve.  A.M.  and  S.C.,  Area  of  distribution  of  the  great  auricular,  superficial  cervical,  and  supra- 
clavicular  branches  of  the  cervical  plexus.  C,  Circumflex  nerve.  W,  Nerve  of  Wrisberg.  I. C.,  In- 
ternal cutaneous  area.  M.S.,  Musculospiral  area.  M.C.,  Musculocutaneous  area.  U,  Ulnar.  M, 
Median.  R,  Radial.  G.C.,  Genitocrural  area.  The  nerve  is  seen  as  distributing  its  branches  to  the 
genital  region  and  to  the  upper  portion  of  the  thigh.  E.G.,  External  cutaneous  area.  1. 1.,  Ilio-in- 

fuinal  area.  I.C.U.,  Internal  cutaneous  area  of  the  thigh.  M.C.U.,  Middle  cutaneous  of  thigh.  I.S., 
nternal  saphenous.  P,  External  popliteal  branches  area.  On  the  right  side  the  division  according 
to  segments  is  seen,  the  letters  C,  D,  L,  and  S  standing  respectively  for  cervical,  dorsal,  lumbar,  and 
sacral  segments  of  the  cord.  On  the  right  side,  from  the  fourth  dorsal  to  the  twelfth  dorsal  (inclu- 
sive), the  maximum  points,  according  to  Head,  of  the  abdominal  viscera  are  shown  in  relation  to  the 
spinal  segments.  (See  Abdomen.) 

349 


THE   SHOULDER    REGION. 


351 


104).  The  deformity  is  corrected  by  bringing  the  arm  well  back  and 
supporting  the  elbow.  Greenstick  fracture  is  very  frequent  in  children. 
Cases  have  been  reported  of  injury  to  the  brachial  plexus  and  to  the  sub- 
clavian  artery  and  vein  from  a  fragment  of  bone  in  fractures  of  the 
clavicle;  but  this  is  rare,  as  stated  above,  owing  to  the  protection 
given  them  by  the  subclavius  muscle. 

At  the  inner  end  of  the  clavicle  is  the  sternoclavicular,  at  its  outer  the 
acromioclavicular  joint.  The  sternoclavicular  joint  is  strongly  protected 
by  ligaments,  so  that  it  is  very  firm  and  only  a  slight  range  of  motion  is 
permitted.  It  is  not  infrequently  the  seat  of  tuberculosis. 


Ext.  jugular  vein 

M.  trapezius 

Clavicular  fascia  of  sternocleidomastoid 

External  extremity  of 

internal  fragment 

Internal  extremity  of 

external  fragment 

Deltoid 


Cephalic  vein 
Pectoral  is  major 


Fig.  104. — Fracture  of  the  middle  portion  of  the  clavicle  (Anger). 

Dislocation  upward  at  this  joint  is  most  frequent,  and  is  due  to  in- 
direct violence,  the  force  acting  upon  the  shoulder.  The  sternoclavic- 
ular joint  is  V-shaped,  a  point  to  be  remembered  in  disarticulating  it  at 
autopsies.  The  acromioclavicular  joint  is  simpler;  its  articular  surfaces 
are  in  a  sagittal  plane  and  are  surrounded  by  a  capsule  strengthened  by 
the  acromioclavicular  ligament  below.  The  two  joint  surfaces  lie  in  a 
plane  which  is  directed  downward  and  inward.  Dislocation  upward  of 
the  outer  end  of  the  clavicle  is  the  more  frequent,  and  the  bone  is  kept  in 
place  with  great  difficulty.  It  is  often  necessary  to  wire  the  two  joint 
surfaces  together. 

The  deep  pectoral  fascia  passes  downward  from  the  clavicle  and  in- 


352  UPPER    EXTREMITY. 

closes  the  pcctoralis  major.  The  costocoracoid  membrane,  a  still  deeper 
layer  of  fascia,  incloses  the  pectoralis  minor  and  unites  with  the  deep 
pectoral  to  form  the  axillary  fascia  lining  the  base  of  the  axilla.  The 
costocoracoid  membrane  is  continuous  with  the  middle  layer  of  the  deep 
cervical  fascia  (see  Fig.  31).  Pus  beneath  the  deep  pectoral  fascia  either 
travels  between  it  and  the  costocoracoid  membrane  to  the  axilla,  or  up- 
ward into  the  neck  (and  anterior  mediastinum).  Pus  beneath  the  axil- 
lary fascia  cannot  escape  toward  the  surface  except  upward,  on  account 
of  the  deep  pectoral  and  costocoracoid  fasciae  in  front,  the  firm  thorax  to 
the  inner  side,  and  the  arm  externally,  and  the  subscapularis  behind. 

At  the  outer  end  of  the  clavicle,  aiding  greatly  in  giving  the  shoulder 
its  convex  outline,  is  the  deltoid  muscle,  separated  from  the  humerus  only 
by  the  subdeltoid  bursa  (see  Fig.  105).  Between  it  and  the  upper  edge  of 
the  pectoralis  major  is  a  groove  in  which  at  a  superficial  level  lie  the 
cephalic  vein  and  acromiothoracic  artery;  at  a  deeper  level  lie  the  cora- 
coid  process  and  pectoralis  minor  muscle,  under  which  can  be  found 
the  brachial  plexus  and  the  axillary  artery  and  vein. 

The  Axilla. — The  skin  covering  the  axilla  contains  many  sebaceous 
and  sweat  glands,  and  is  a  frequent  seat  of  abscesses  of  the  same.  Be- 
neath the  superficial  fascia  is  the  deep  or  axillary  (see  above).  The  con- 
nective tissue  of  the  axilla  beneath  the  fascia  is  very  loose  and  contains 
much  fat  and  a  large  number  of  lymph-glands,  lying  chiefly  along  the 
vessels,  receiving  the  lymph  from  the  front  and  back  of  the  chest  and 
from  the  upper  extremity.  They  are  continuous  with  the  deep  cervical 
glands  (see  Fig.  106).  They  enlarge  in  all  inflammatory  conditions,  and 
in  cases  of  malignant  neoplasms  occurring  in  the  regions  drained  by 
them,  and  are  best  examined  when  the  fascia  is  relaxed,  i.  e.,  with  the  arm 
brought  to  side  of  chest.  The  course  of  abscesses  resulting  from  them 
has  been  described  above. 

The  intercosto-humeral  nerve  passes  directly  through  the  fat  of  the 
axilla.  The  axillary  veinMies  in  front  of  the  axillary  artery  (when  the  arm 
is  extended).  It  is  often  double,  and  thus  frequently  cut  in  operations 
involving  the  axilla.  Above  the  artery  lies  the  median  nerve,  below  it 
the  ulnar  and  middle  cutaneous  nerves,  behind  it  the  musculospiral  and 
posterior  circumflex  nerves  (see  Fig.  94).  From  the  artery  is  given  off 
the  long  thoracic,  which,  accompanied  by  the  corresponding  vein  and 
nerve,  lies  upon  the  serratus  magnus  muscle,  supplying  it  (see  Fig.  46). 
A  little  more  distally  the  subscapular  artery  is  given  off  from  the  axillary. 
The  long  thoracic  nerve  is  often  severed  during  operations  on  the  breast 
unless  its  position  is  borne  in  mind,  the  result  of  such  injury  being  a 
paralysis  of  the  serratus  magnus  muscle  which  it  supplies.  The  serratus 


BSS-CfcBii.fi 

C    <T>    O     -••-»-    n    5. 
oo      3    _3      3     n>      3     o 
X      ^     H 


353 


Fig.  1 06. — Principal  superficial  and  deep  lymphatics  on  anterior  surface  of  extremities 
and  trunk,  i,  Supraclavicular.  2,  Axillary.  3,  Cubital.  4,  Bronchial.  5,  Anterior 
mediastinal.  On  the  right  side  these  are  seen  below  the  bronchial,  communicating  with 
7,  those  of  the  liver  (see  Fig.  54).  6,  Anterior  intercostal.  8,  Plexus  of  lymphatics  around 
celiac  axis,  receiving  the  lymph  from  the  principal  solid  abdominal  viscera.  9,  Lumbar 
lymphatics,  which  receive  the  lymph  from  10,  the  deep  iliac  lymphatics,  and  also  those 
from  the  pelvis.  11,  Superficial  inguinal  lymphatics,  which  receive  the  lymph  from  the 
lower  half  of  the  back  and  abdomen,  and  from  the  external  genitals,  and  lower  portion  of 
the  rectum  and  vagina.  12,  Inguinal  lymphatics  over  saphenous  opening,  which  receive 
the  lymph  from  the  lower  extremity,  and  occasionally  from  the  external  genitalia.  In  this 
figure  the  superficial  lymphatics  are  shown  as  a  hollow  circle,  the  deep  ones  as  a  solid  one. 
1 3,  Location  of  swelling  in  effusion  into  shoulder-joint.  14,  Same  of  knee-joint. 

355 


THE    SHOULDER    REGION.  357 

magnus,  through  its  attachment  along  the  vertebral  border  of  the  scap- 
ula, serves  to  fix  the  scapula  to  the  chest-wall  when  the  arm  is  raised. 
When  paralyzed,  this  function  is  lost,  the  vertebral  border  of  the  scapula 
stands  out,  and  there  is  considerable  difficulty  in  raising  the  arm.  The 
nerve  may  be  paralyzed  independent  of  any  operation,  the  patient  then 
complaining  of  being  unable  to  raise  the  arm  as  well  as  before.  From  its 
posterior  surface  the  posterior  circumflex  artery  winds  around  the  upper 
end  of  the  humerus,  accompanied  by  the  posterior  circumflex  nerve. 
This  nerve  supplies  the  deltoid,  shoulder-joint,  and  two  teres  muscles, 
and  is  frequently  injured  in  fractures  of  the  upper  end  of  the  humerus, 
resulting  in  paralysis  of  the  deltoid  with  great  atrophy  (see  Figs.  97  and 
108).  The  wasting  of  the  deltoid  muscle  is  extensive  after  any  injury 
to  the  shoulder-joint,  even  a  simple  sprain,  and  must  be  borne  in  mind 
in  the  after-treatment  of  such  injuries.  Otherwise  the  convalescence  will 
be  extremely  slow. 

The  vessels  and  nerves  of  the  axilla  lie  directly  over  the  lower  portion 
of  the  shoulder-joint,  and  are  often  compressed  in  subcoracoid  disloca- 
tion of  the  humerus  (see  Fig.  92). 

The  shoulder-joint  (see  Figs.  105  and  107)  is  formed  by  the  head 
of  the  humerus  and  the  glenoid  cavity.  The  latter  is  slightly  concave 
and  the  head  of  the  humerus,  which  is  almost  spherical,  projects  beyond 
the  edge  of  the  joint  surface  of  the  glenoid  cavity.  The  joint  is  crossed  in 
front  by  the  subscapularis  muscle  as  it  passes  to  the  lesser  tuberosity. 
To  the  outer  side  of  this  muscle  lies  the  tendon  of  the  long  head  of  the 
biceps,  which  runs  in  a  synovial  sheath,  almost  always  in  communication 
with  the  joint  (see  Fig.  105). 

Above,  the  joint  is  strengthened  by  the  coracohumeral  ligament  in- 
serted into  the  anatomic  neck  of  the  humerus.  This  ligament  is  firmly 
adherent  to  the  capsule  of  the  joint  and  to  the  supraspinatus  tendon  lying 
above  it.  The  joint  capsule  is  strengthened  behind  by  the  tendons  of  the 
infraspinatus  and  teres  minor,  which  are  firmly  adherent  to  the  capsule. 
The  capsule  extends  in  front  as  far  as  the  anatomic  neck;  behind,  a  little 
further  down  (see  Fig.  107).  The  capsule  is  almost  double  the  volume  of 
the  head  of  the  humerus.  Its  weakest  points  are  between  the  long  head 
of  the  biceps  and  subscapularis  above  (just  below  the  coracoid  process), 
and  also  between  the  subscapularis  and  teres  minor  below.  When  the 
joint  is  opened,  the  biceps  tendon,  which  arises  from  the  upper  edge  of 
the  glenoid  cavity,  is  seen  to  pass  across  the  upper  surface  (Fig.  105). 
The  deltoid  muscle  lies  just  over  the  outer  aspect  of  the  joint,  covering 
it  like  a  curtain,  separated  only  by  a  large  subdeltoid  bursa  (which 
occasionally  communicates  with  the  joint]  from  the  upper  end  of  the 


358  UPPER   EXTREMITY. 

humerus.  Hence,  when  the  head  of  the  humerus  leaves  the  glenoid  cav- 
ity, as  in  dislocations,  the  deltoid  sinks  in,  and  there  is  a  concavity  or 
depression  below  the  acromion  process  (see  Fig.  92).  The  arch  formed 
by  the  acromion  and  the  coracoid  processes,  and  the  strong  ligaments 
between  them,  protect  the  joint  above  from  direct  injury. 

The  arm  can  be  flexed  to  a  right  angle  at  the  shoulder-joint,  which 
action  is  chiefly  carried  out  by  the  deltoid ;  then  if  the  scapula  is  fixed  by 
the  serratus  magnus,  the  arm  can  be  raised  almost  vertically.  The  arm 
can  only  be  extended  70  to  80  degrees  (see  Fig.  95).  It  can  be  adducted 
only  as  far  as  the  thorax,  but  can  be  abducted  with  the  aid  of  the  scapular 
muscles  almost  vertically.  The  shoulder- joint  is  frequently  the  seat  of 
both  acute  and  chronic  disease.  Infection  may  extend  into  it  from  the 
axilla  through  the  weak  points  in  the  capsule,  or  through  the  subdeltoid 
bursa,  which  the  author  has  seen  secondarily  involved  in  infections  of  the 
arm.  Severe  pain  is  then  caused  by  any  movement  of  the  arm,  the  con- 
tour of  the  shoulder  is  increased,  and  the  deltoid  is  expanded  by  the  fluid 
swelling  under  it,  especially  noticeable  at  its  anterior  border  (see  Fig. 
1 06).  The  axilla  also  shows  a  painful  swelling.  Inflammation  of  the 
subdeltoid  bursa  may  simulate  this,  but  there  is  no  swelling  in  the  axilla 
or  pain  on  movement  of  the  joint.  The  shoulder-joint  is  seldom  the  seat 
of  a  chronic  process,  especially  tuberculosis.  If  the  latter  affects  the 
joint,  abscesses  point  either  in  front  of  or  behind  the  axilla.  The 
shoulder-joint  is  opened  to  excise  the  joint  surfaces  in  tuberculosis,  or  to 
drain  the  same  for  acute  infections.  An  incision  is  made  from  a  point 
midway  between  the  acromion  and  coracoid  processes  and  the  fibers  of 
the  deltoid  are  incised  down  to  the  capsule.  The  cephalic  vein  and  ac- 
companying artery  must  be  held  inward,  the  long  head  of  the  biceps  out- 
ward. The  upper  epiphysis  of  the  humerus  includes  the  head  and 
the  greater  part  of  the  tuberosities  (see  Fig.  107)  and  the  capsule  is 
mainly  attached  to  the  epiphysis;  hence,  in  children  (see  Fig.  102)  sepa- 
ration of  the  upper  epiphysis  simulates  dislocation,  and  disease  in  the 
upper  end  of  the  diaphysis  does  not  necessarily  involve  the  cavity  of  the 
joint. 

Dislocations  of  the  shoulder-joint  may  be  either  congenital  or 
acquired.  The  latter  are  far  more  frequent. 

Dislocation  at  the  shoulder-joint  is  favored 

1.  By  the  fact  that  the  head  projects  beyond  the  margins  of  the 
glenoid  cavity.    (Fig.  105.) 

2.  The  glenoid  cavity  is  very  shallow,  so  that  the  head  of  the  humerus 
can  readily  slip  out. 

3.  The  capsule  is  not  strengthened  by  firm  ligaments,  but  only  by 


Fig.  107. — Vertical  section  of  shoulder-joint.  The  right  half  of  the  figure  repre- 
sents the  posterior  half;  the  left  the  anterior  half.  E,  Epiphyseal  cartilage,  between 
epiphysis  (i)  and  diaphysis  (2).  3,  Glenoid  cavity  of  scapula,  showing  its  small  size 
as  compared  with  that  of  the  head  of  the  humerus.  4,  Acromion  process.  Above  it  is 
seen  the  outer  end  of  the  clavicle.  5,  Cavity  of  shoulder-joint,  showing  extent  of  joint 
surface  and  synovial  membrane.  6,  Brachial  vessels  and  nerves. 


359 


THE    SHOULDER    REGION.  361 

muscles  or  tendons,  being  protected  above  by  the  acromioclavicular 
arch. 

4.  In  falls  upon  the  upper  extremity,  in  order  to  break  the  force 
of  the  injury,  the  arm  is  abducted  so  that  the  head  of  the  humerus 
is  brought  in  contact  with  the  weakest  part  of  the  capsule  (the  in- 
ferior), and  escapes  toward  the  axilla,  and  then,  by  the  action  of 
the  pectoral  muscles,  is  most  frequently  pulled  forward,  so  that  it  rests 
under  the  coracoid  process.  If  the  force  is  applied  from  the  front, 
the  head  may  be  pulled  back  by  the  scapular  muscles. 

In  all  varieties  of  dislocations  the  normal  contour  of  the  shoulder  is 
absent,  there  is  a  concavity  or  depression  below  the  acromion,  the  axis 
of  the  humerus  is  changed,  and  the  arm  is  lengthened  (see  Fig.  92). 
The  arm  is  flexed  by  the  biceps  and  abducted  by  the  deltoid.  In  the 
subcoracoid  variety  (the  most  frequent)  the  head  can  be  felt  just 
below  the  outer  end  of  the  clavicle.  There  is  rigidity  at  the  shoulder- 
joint.  In  the  subglenoid  variety  the  head  of  the  bone  is  felt  in  the 
axilla,  resting  against  the  outer  border  of  the  scapula,  and  there  is 
marked  abduction  of  the  arm. 

In  subcoracoid  dislocation  the  subscapularis  muscle  is  stretched 
over  the  head  of  the  bone,  the  supraspinatus  and  infraspinatus  and 
teres  minor  are  very  tense,  and  may  be  torn. 

The  axillary  vessels  and  brachial  plexus  lie  between  the  chest-wall 
and  the  head  of  the  humerus,  and  are  apt  to  be  compressed  if  the  dis- 
location is  not  recognized.  Kocher's  method  of  reduction  depends  upon 
the  fact  that  (a)  when  the  arm  which  has  been  adducted  until  the 
elbow  touches  the  side  is  rotated  outward,  the  capsule  and  muscles  are 
stretched,  allowing  the  rent  in  the  capsule  to  gape;  (b)  when  the  arm  is 
elevated,  the  head  is  brought  opposite  the  rent  and  the  arm  being 
carried  toward  the  opposite  shoulder  allows  the  head  to  slip  back  into 
the  glenoid  cavity. 

For  a  description  of  the  other  varieties  of  dislocation  and  their 
reduction,  see  books  on  fractures,  etc. 

Fractures  of  the  Upper  End  of  the  Humerus. — These  may  be : 

1.  Fracture  of  anatomic  neck  (chiefly  in  old  people). 

2.  Separation  of  the  upper  epiphysis  (up  to  the  twentieth  year). 

3.  Fracture  of  the  surgical  neck. 

In  order  to  examine  the  upper  end  of  the  humerus,  it  should  be 
grasped  between  the  fingers  and  thumb  of  one  hand,  pressed  under  the 
spinous  and  acromion  processes,  i.  e.,  in  front  of  and  behind  the  deltoid, 
the  elbow  being  held  flexed  in  the  palm  of  the  other  hand.  By  moving 
the  humerus  in  different  directions  crepitus  and  false  point  of  motion 


362  UPPER    EXTREMITY. 

(unless  the  fracture  is  an  impacted  one)  can  be  readily  obtained.  The 
length  of  the  humerus  should  be  measured  from  the  acromion  to  the 
external  condyle  (see  Fig.  93).  If  the  head  rotates  with  the  shaft, 
there  is  probably  no  fracture.  If  it  does  not,  there  is. 

1.  Fracture  0}  the  Anatomic  Neck. — This  is  an  intracapsular  frac- 
ture, always  due  to  falls  or   blows   on  the    shoulder.     The  latter  is 
swollen,  the  head  of  the  humerus  is  felt  to  be  irregular,  and  crepitus 
can  be  obtained  unless  there  is  impaction. 

2.  Separation  oj  the  Upper  Epiphysis. — The  upper  epiphysis  (Fig. 
102)  joins  the  shaft  at  the  age  of  twenty.     Before  that  time  the  shaft 
may  be  torn  almost  horizontally  across,  below  the  epiphyseal  cartilage, 
the  epiphysis  itself  being  often  rotated  so  that  its  articular  surface  looks 
downward  and  the  lower  fragment  is  felt  just  below  the  coracoid, 
being  pulled  up  and  inward  by  the  pectoral  muscles. 

3.  Fractures  oj  the  Surgical  Neck  (see  Fig.  108). — These  include  all 
fractures  below  the  epiphyseal  line,  situated  in  the  upper  fourth  of  the 
bone.    They  usually  result  from  blows  on  the  shoulder  or  falls  on  the  hand 
or  elbow.     The  fracture  is  usually  transverse,  the  lower  fragment  is 
drawn  inward  by  the  pectoral  muscles,  and  upward  by  the  biceps,  triceps, 
deltoid,  and  coracobrachialis.     The  upper  fragment  is  rotated  outward 
by  the  muscles  attached  to  the  tuberosities  and  adducted  by  the  sub- 
scapularis.    It  may  leave  the  glenoid  cavity  completely.    On  account  of 
the  fact  that  the  circumflex  nerve  passes  around  the  shaft  of  the  humerus, 
it  may  be  greatly  stretched  and  torn  in  dislocations  of  the  shoulder, 
or  may  be  torn  or  caught  between  the  fragments  in  a  fracture  of  the 
surgical  neck  with  resultant  paralysis  of  the  deltoid  muscle.     In  this 
fracture  there  is  always  a  depression  just  below  the  shoulder,  but  not  such 
a  marked  loss  in  its  contour  as  in  a  dislocation. 

Scapular  Region. 

The  skin  of  this  region  is  firmer  than  that  of  the  remainder  of  the 
shoulder.  The  subcutaneous  tissue  is  frequently  the  seat  of  lipomata. 
As  far  as  the  spine,  the  upper  portion  of  the  scapula  is  covered  by  the 
trapezius,  beneath  which  is  the  supraspinatus  muscle  in  the  correspond- 
ing fossa,  which  passes  across  to  the  greater  tuberosity  of  the  humerus. 
The  fossa  below  the  spine  is  to  be  more  distinctly  palpated.  It  is 
filled  out  by  the  infraspinatus  and  teres  minor,  which  pass  across  to  the 
tuberosity  of  the  humerus.  The  insertion  of  these  muscles  is  covered 
by  the  deltoid,  and  between  the  latter  and  the  neck  (surgical)  of  the 
humerus  at  this  point  the  posterior  circumflex  artery  and  circumflex 
nerve  lie,  passing  backward  from  the  axilla  and  then  curving  around 


Fig.  108. — Dissection  of  a  fracture  of  surgical  neck  of  the  humerus  (modified  from 
Helferich  and  Hoffa),  showing  how  the  circumflex  nerve  as  it  winds  around  the  posterior 
aspect  of  the  surgical  neck  of  the  humerus  may  be  caught  in  the  callus;  also  showing 
the  change  in  the  contour  of  the  shoulder. 


363 


BRACHIAL   OR    UPPER    ARM    REGION.  365 

the  upper  end  of  the  humerus  (see  Fig.  97).  On  the  anterior  surface 
of  the  scapula  lies  the  subscapularis  muscle,  which  passes  across  the 
front  of  the  shoulder-joint,  forming  in  part  the  posterior  wall  of  the 
axilla.  Fracture  of  the  scapula  is  very  rare,  and  usually  due  to  direct 
violence.  Fracture  of  the  acromion  is  most  frequent,  that  of  the  body 
or  neck  being  very  rare.  If  the  acromion  is  broken,  the  shoulder  is 
flattened.  Crepitus  may  at  times  be  felt.  Fracture  of  the  neck  of  the 
spine  of  the  scapula  may  be  mistaken  for  a  dislocation.  The  arm  is 
lengthened,  but  on  lifting  it  the  deformity  is  corrected  and  crepitus  is 
detected;  but  if  this  upward  pressure  is  removed,  the  deformity  recurs. 

Brachial  or  Upper  Arm  Region. 

The  skin  is  fine  on  the  anterior,  coarser  on  the  posterior  aspect. 
It  is  very  movable,  adapting  itself  readily  to  plastic  operations.  In  the 
subcutaneous  tissue,  which  does  not  contain  much  fat,  there  are  many 
veins,  emptying  on  the  outer  side  into  the  cephalic  vein  and  on  the  inner 
into  the  basilic  veins.  Both  of  these  larger  veins  lie  in  this  layer,  the 
cephalic  in  the  groove  to  the  outer  side,  the  basilic  in  that  on  the  inner 
side  of  the  biceps  muscle  (see  Fig.  100).  There  are  many  subcutaneous 
lymphatic  vessels  lying  principally  along  the  inner  side  of  the  arm  and 
emptying  into  the  axillary  glands  (see  Fig.  106).  The  superficial  nerves 
are  derived  from  the  circumflex,  intercosto-humeral,  internal  cutaneous, 
and  musculospiral  above  the  elbow  (Fig.  103).  Beneath  the  subcutane- 
ous tissue  is  a  fascia  thin  in  front,  firmer  behind.  It  is  continuous 
above  with  the  axillary  and  along  the  inner  and  outer  aspects  of 
the  arm  it  passes  inward  to  the  humerus,  forming  an  internal  and 
an  external  intermuscular  septum,  thus  dividing  the  arm  into  an 
anterior  compartment,  containing  the  median  nerve,  brachial  artery 
and  veins,  brachialis  anticus,  biceps,  and  coracobrachialis  muscles; 
and  a  posterior  compartment,  containing  the  triceps,  the  musculospiral 
nerve,  and  superior  profunda  artery  (see  Fig.  109).  The  ulnar 
nerve  lies  at  first  to  the  inner  side  of  the  median  nerve  in  the  anterior 
compartment  (Fig.  109),  penetrates  the  internal  intermuscular  septum 
lower  down,  and  lies  in  the  posterior  compartment  (see  Fig.  94).  The 
brachial  artery  begins  at  the  point  of  insertion  of  the  pectoralis  major, 
runs  along  the  inner  side  of  the  biceps  to  the  bend  of  the  elbow,  where 
it  divides  into  the  ulnar  and  radial  arteries.  Its  largest  branch  (the 
superior  profunda)  accompanies  the  musculospiral  nerve  (see  Fig.  109). 
The  brachial  may  divide  into  the  above  two  vessels  higher  up  (middle 
third  of  upper  arm),  one  artery  lying  in  front  of,  the  other  behind,  the 
median  nerve.  The  median  nerve  normally  lies  to  the  outer  side  of 


366  UPPER    EXTREMITY. 

the  artery  in  the  upper  third,  then  in  front  of  it  (middle  third),  and 
below  (lower  third)  it  crosses  the  artery  lying  to  the  inner  side.  When 
an  artery  is  found  in  front  of  it,  a  larger  one  must  be  looked  for 
behind  it. 

The  musculocutaneous  nerve  leaves  the  brachial  artery  opposite  the 
middle  of  the  coracobrachialis,  passes  between  this  muscle  and  the  biceps 
to  the  external  condyle. 

The  ulnar  nerve  lies  to  the  inner  side  of  the  brachial  artery  in  the 
upper  third  of  the  arm  (Fig.  109);  it  then  pierces  the  internal  inter- 
muscular  septum  to  reach  the  internal  condyle,  passing  between  the 
latter  and  the  olecranon  (Fig.  98),  joining  the  ulnar  artery  a  little  below 
the  bend  of  the  elbow  (Fig.  96). 

The  musculospiral  nerve,  accompanied  by  the  superior  profunda 
artery,  leaves  the  upper  part  of  the  brachial  artery,  winds  around  the 
shaft  of  the  humerus  between  the  triceps  and  the  bone  (Fig.  109), 
piercing  the  external  intermuscular  septum  just  above  the  external 
condyle.  At  this  point  it  divides  into  the  posterior  interosseous  and 
radial  nerves.  In  amputations  it  must  be  cut  by  the  knife  straight 
across  with  the  bone,  or  else  it  will  be  torn  by  the  saw.  In  such  ampu- 
tation at  the  middle  of  the  upper  arm,  the  anterior  flap  contains  the 
brachial  vessels,  median  nerve,  biceps,  coracobrachialis,  and  brachialis 
anticus  muscles ;  the  posterior  flap  contains  the  ulnar  and  musculospiral 
nerves,  the  superior  profunda  artery,  and  the  triceps  muscle  (see  Fig.  109). 
Further  down,  near  the  elbow,  the  musculospiral  would  lie  in  the 
anterior  flap. 

The  best  points  to  test  the  painfulness  of  the  nerves  of  the  brachial 
region  in  cases  of  neuritis  are  the  outer  aspect  of  the  middle  of  the 
shaft  of  the  humerus  for  the  musculospiral,  the  groove  between  the 
internal  condyle  and  the  olecranon  for  the  ulnar  nerve,  and  pressure 
over  the  external  condyle  for  the  radial  nerve.  The  main  trunks  of 
the  ulnar  and  median  can  be  pressed  upon  close  to  the  axilla  along  the 
inner  border  of  the  biceps. 

Fracture  of  the  Shaft  of  the  Humerus.— Is  most  frequent  at 
the  middle  third  of  the  bone.  There  is  usually  but  little,  if  any,  dis- 
placement. The  deltoid  and  pectoralis  major  muscles  may  pull  the 
upper  fragment  up  and  inward;  the  triceps,  the  lower  fragment  back- 
ward (see  Fig.  no). 

These  fractures  are  of  interest  on  account  of  the  frequency  with 
which  the  musculospiral  nerve  is  injured  at  the  time  of  the  accident, 
either  torn  across  by  the  original  violence  or  lacerated  by  the  ends  of 
the  fragments;  occasionally  it  is  included  in  the  callus.  Such  injury 


Cephalic  vein 

Brachial  artery 

Musculospiral  nerve 

Triceps 


Biceps 

Median  nerve 
Basilic  vein 
Ulnar  nerve 


Fig.  109. — Cross-section  at  middle  of  arm. 


367 


THE    ELBOW    REGION.  369 

gives  rise  to  the  characteristic  wrist-drop  (paralysis  of  the  extensors  of 
the  forearm  and  wrist)  and  anesthesia  of  the  radial  side  of  the  forearm 
and  fingers  (see  Fig.  118).  Fractures  of  the  shaft  are  of  interest  also 
on  account  of  the  frequency  of  non-union.  This  is  frequently  due  to 
the  lack  of  support  to  the  elbow,  allowing  too  much  motion,  and  also 
to  the  interposition  of  muscle. 

The  Elbow  Region. 

The  surface  anatomy  has  been  given  above.  The  skin  of  the 
anterior  surface  is  thin,  that  of  the  posterior  much  thicker.  Just  be- 
neath the  skin,  in  front,  lie  the  veins  spoken  of  under  the  examination 
of  the  living  arm  (Figs.  99  and  100),  the  median  vein,  as  it  returns  from 
the  forearm,  dividing  at  the  end  of  the  elbow  into  the  median  basilic, 
which  unites  with  the  ulnar  vein  to  form  the  basilic  vein,  and  the 
median  cephalic,  which  unites  with  the  radial  vein  to  form  the  cephalic. 
Smaller  veins  pass  through  the  fascia  which  serve  to  connect  these  super- 
ficial with  the  deep  veins.  In  phlebotomy  at  the  elbow  the  median  basilic 
is  most  frequently  opened,  the  arm  being  compressed  above  to  render  it 
more  prominent.  The  superficial  lymphatics  accompany  the  veins  and 
are  most  numerous  over  the  inner  condyle,  emptying  into  the  cubital 
glands  situated  just  above  this  prominence  (Fig.  106).  In  infections  of 
the  ulnar  side  of  the  forearm  or  hand  this  gland  is  affected,  while  in  those 
of  the  radial  side  the  infected  lymph  is  carried  directly  to  the  axillary 
glands  (Figs.  53  and  106).  The  superficial  nerves  in  front  are  the  internal 
and  external  cutaneous;  behind,  the  cutaneous  branches  of  the  musculo- 
spiral  and  intercosto-humeral  nerves  (Fig.  103).  In  front  of  the  elbow 
the  fascia  is  strengthened  by  the  bicipital  fascia,  an  aponeurosis  covering 
the  brachial  artery  and  median  nerve,  continuous  with  the  biceps. 
Beneath  the  bicipital  fascia  lies  in  front  of  the  joint  the  brachial  artery,  to 
the  inner  side  of  the  biceps  tendon,  dividing  beneath  the  bicipital  fascia 
into  the  radial,  lying  more  superficially,  and  the  ulnar.  At  this  point, 
aneurisms  of  the  brachial  not  infrequently  occur,  and  it  is  important 
to  bear  in  mind  that  the  radial,  soon  after  its  origin,  gives  off  a  recurrent 
branch  which  anastomoses  with  the  superior  profunda  artery,  a  branch 
of  the  brachial.  When  the  elbow  is  flexed,  the  brachial  artery  is  com- 
pressed; hence,  to  judge  of  the  quality  of  a  patient's  radial  pulse,  the 
arm  should  always  be  straightened.  The  muscular  prominence  to  be 
seen  and  felt  through  the  skin  on  the  inner  side  of  the  biceps  tendon  is 
formed  by  the  pronator  radii  teres,  the  flexor  carpi  ulnaris,  palmaris 
longus,  and  flexor  carpi  radialis.  The  prominence  on  the  outer  side 
is  formed  by  the  supinator  longus,  beneath  which  lie  the  extensors. 


37O  UPPER    EXTREMITY. 

On  the  posterior  aspect  of  the  elbow  is  seen  the  triceps  tendon, 
inserted  into  the  olecranon  process.  Between  the  latter  and  the  skin 
is  the  olecranon  bursa,  which  frequently  inflames  after  falls  upon  the 
elbow  (see  Fig.  98).  To  either  side  of  the  olecranon  process  are  two 
depressions  normally  which  are  obliterated  in  cases  of  effusion  in  the 
joint  (see  Fig.  53).  This  is  the  first  place  at  which  a  synovitis 
with  fluid  exudate  shows  itself  and  the  elbow-joint  can  best  be 
drained  and  explored  through  the  outer  depression.  Over  the  inner  of 
these  depressions  lie  the  anastomoses  of  the  ulnar  recurrent  artery 
with  the  brachial  artery,  which  assist  in  establishing  a  collateral  cir- 
culation. In  this  inner  space  lies  the  ulnar  nerve,  which  must  be 
avoided  in  resection  of  the  elbow.  For  the  same  reason  exploratory 
puncture  is  best  made  through  the  outer  space  or  depression.  The 
elbow- joint  is  formed  by  the  articular  surfaces  of  the  lower  end  of  the 
humerus  and  of  the  upper  ends  of  the  radius  and  ulna  (see  Fig.  in). 
The  humerus  and  ulna  form  a  firm  hinge-joint  in  which  only  flexion  and 
extension  are  possible,  being  especially  strengthened  by  the  olecranon  pos- 
teriorly. The  humerus  and  radius  form  a  ball-and-socket  joint  in  which 
free  movement  is  possible,  notably  extension  and  flexion,  but  also  rota- 
tion. The  joint  between  the  radius  and  ulna  permits  only  of  rotary  move- 
ments. The  elbow- joint  capsule  is  thin,  especially  posteriorly  over  the  ole- 
cranon fossa.  It  is  greatly  strengthened  laterally  by  ligaments,  but  in  front 
and  behind  is  quite  weak.  For  this  reason  antero -posterior  dislocations 
are  quite  common,  lateral  are  rare.  The  forward  dislocation  occurs  when 
the  arm  is  strongly  flexed,  the  olecranon  sliding  forward  on  the  anterior 
surface  of  the  joint.  Backward  dislocations  (Fig.  112)  are  the  most 
common,  being  frequently  associated  with  fracture  of  the  coronoid 
process  of  the  ulna.  They  occur  during  hyperextension  (falls  on  out- 
stretched hand),  the  coronoid  slipping  across  the  articular  surface. 

Fractures  of  the  Elbow. — The  most  important  point  in  the  ex- 
amination of  the  elbow  is  to  determine  the  relations  of  the  three  bony 
prominences,  the  condyles  and  olecranon,  to  each  other  (see  Fig.  98), 
and  also  to  determine  whether  the  movements  of  the  radius  upon  the 
humerus,  as  felt  just  below  the  external  condyle,  are  normal.  When  the 
elbow  is  flexed,  these  three  bony  landmarks  form  a  triangle,  the  olecranon 
being  J  inch  lower.  When  the  elbow  is  extended,  they  lie  in  one  line 
(see  Fig.  98).  These  were  referred  to  under  Examination  of  Upper 
Extremity  during  Life.  The  most  frequent  form  of  injury  is  either  a 
dislocation  backward  of  both  bones  of  the  forearm,  or  a  fracture  of  the 
humerus  above  the  condyles  (especially  in  children).  For  systematic 
examination  it  is  best  to  remember  that  one  of  the  following  conditions 
can  be  present: 


THE    ELBOW    REGION.  371 

Lesions  of  Radius  and  Ulna. 

(a)  Dislocation  of  the  radius  and  ulna  backward,   with  or 

without  fracture  of  the  coronoid  process. 

(b)  Subluxation  of  the  radial  head  (in  children). 

(c)  Fracture  of  olecranon  process. 

(d)  Fracture  of  head  or  neck  of  radius. 

Lesions  of  Lower  End  of  Humerus. 

(a)  Fracture  of  internal  epicondyle. 

(b)  Fracture  of  internal  condyle. 

(c)  Fracture  of  external  condyle. 

(d)  Supracondyloid  fracture  (transverse). 

(e)  Separation  of  lower  epiphysis. 

(/)  Transverse  fracture  into  elbow- joint — T  or  Y. 

Ankylosis  is  very  apt  to  follow  after  any  injury  to  the  elbow,  even  a 
simple  sprain,  unless  great  care  is  exercised  to  establish  early  passive 
motion. 

Dislocations  of  the  Elbow. — These  may  be  in  one  of  four  direc- 
tions, but  are  by  far  more  frequent  backward,  involving  both  radius 
and  ulna.  The  reason  why  backward  dislocation  of  these  bones 
is  the  most  frequent  is  that  the  accident  which  causes  it  is  a  fall 
upon  the  outstretched  arm,  the  hand  being  held  in  a  prone  position. 
The  result  is  a  forcible  abduction  and  extension,  the  coronoid  process 
either  breaks  off  or  slips  over  the  lower  end  of  the  humerus  without 
being  broken.  The  addition  of  violence  transmitted  along  the  forearm 
forces  the  ulna  and  radius  over  the  posterior  aspect  of  the  joint  surface 
of  the  humerus. 

In  these  cases  the  forearm  is  shortened.  The  olecranon  is  situated 
above  the  line  drawn  between  the  two  condyles  and  one  can  feel  the  inner 
margin  of  the  greater  sigmoid  cavity.  Externally  the  head  of  the 
radius  can  be  felt  close  behind  the  external  condyle. 

There  may  be  a  dislocation  of  either  radius  or  ulna  alone ;  that  of  the 
former  is  more  frequent,  and  of  this  the  forward  variety.  The  mode 
of  production  is  not  clear.  It  is  due  either  to  direct  violence  or  to 
excessive  pronation  combined  with  traction.  A  similar  dislocation 
occurs  in  children,  but  is  an  incomplete  one  (subluxation).  There  is 
no  change  in  the  relations  of  the  bones.  Passive  motion  is  free,  but 
painful,  except  supination.  On  forced  supination  a  slight  click  is 
heard.  The  injury  consists  in  the  escape  of  the  head  of  the  radius 
below  the  orbicular  ligament.  It  is  produced  by  traction  and  adduction 
of  the  extended  forearm  in  children. 

Fractures  of  the  Olecranon  Process. — These  are  usuallv  due  to 


372  UPPER    EXTREMITY. 

direct  violence  and  are  transverse  about  the  middle  of  the  process. 
There  is  usually  considerable  separation  of  the  fragments,  the  upper 
being  pulled  upward  by  the  triceps  muscle.  The  fragments  are 
brought  closer  together  when  the  arm  is  extended.  There  is  usually 
great  swelling  of  the  elbow,  the  fracture  opening  into  the  joint 
(Fig.  112). 

Fracture  of  the  Neck  or  Head  of  the  Radius. — Very  uncommon. 
There  is  swelling  over  radial  head  and  neck,  and  loss  of  rotation  of 
same. 

Fractures  at  Lower  End  of  Humerus. — The  supracondyloid 
fracture  is  the  most  common,  especially  in  young  persons  (Fig.  no). 
The  fracture  is  transverse  above  the  olecranon  fossa  and  is  most  fre- 
quently due  to  a  fall  upon  the  elbow.  The  front  of  the  elbow  is  fuller 
on  account  of  the  upper  fragment  being  displaced  forward.  The  three 
bony  points  maintain  their  relations.  Abnormal  lateral  and  antero- 
posterior  mobility  and  crepitus  are  found  above  the  elbow-joint. 

The  T-shaped  fracture  and  separation  of  the  epiphysis  resemble 
greatly  the  former  (the  epiphyseal  fracture  occurring  under  ten  years) 
(Fig.  102).  In  the  T-shaped  fractures  the  relations  of  the  bony  points 
will  be  changed,  according  as  one  or  both  condyles  are  displaced. 

Fracture  of  Internal  Epicondyle. — (Tip  of  internal  condyle.) 
Is  quite  common  in  infants.  There  is  but  little  displacement.  If 
the  fragment  is  small,  it  is  of  little  consequence. 

Fracture  of  the  Internal  Condyle. — The  inner  of  the  three  bony 
points  is  displaced  upward.  The  line  of  separation  passes  into  the 
joint.  The  fragment  is  often  placed  upward  and  may  give  rise  to  a 
gunstock  deformity. 

Fracture  of  the  External  Condyle. — The  normal  relations  of 
the  three  bony  points  are  disturbed.  External  condyle  displaced 
upward. 

Diseases  of  the  Elbow-joint. — This  joint  is  frequently  the  seat 
of  both  acute  and  chronic  synovitis;  of  the  former,  the  rheumatic  and 
purulent,  of  the  latter  the  tubercular  variety.  The  presence  of  an 
effusion  in  the  joint  first  shows  itself  by  a  bulging  to  both  sides  of  and 
above  the  olecranon;  less  frequently  over  the  radio-humeral  articula- 
tion (see  Fig.  53).  If  sinuses  due  to  spontaneous  discharge  of  the 
effusion  are  present,  they  are  most  often  situated  to  either  side  of  the 
triceps  tendon.  The  limb  is  held  flexed,  usually  midway  between 
pronation  and  supination. 


Fig.  no. — Dissection  on  the  right  arm  of  a  supracondyloid  fracture  of  the  humerus 
showing  the  backward  displacement  of  the  lower  fragment  by  the  triceps.  On  the  left 
arm  is  shown  a  fracture  in  the  middle  of  the  shaft  of  the  humerus  showing  how  the 
musculospiral  nerve  may  be  included  in  a  callus  or  between  the  fragments. 


373 


Fig.  in. — Backward  dislocation  of  both  bones  of  the  elbow  and  fracture  of  both 
bones  of  the  forearm  (modified  from  Helferich  and  Hoffa).  The  upper  of  the  two  figures 
shows  a  backward  dislocation  of  the  elbow-joint,  both  bones  being  involved,  showing 
the  prominence  on  the  back  of  the  elbow  in  this  form  of  dislocation.  The  lower  of  the 
two  illustrations  is  a  fracture  of  both  bones  of  the  forearm  in  the  middle  third,  showing 
the  action  of  the  pronator  radii  teres  in  rotating  the  upper  fragment  of  the  radius,  of  the 
pronator  quadratus  in  approximating  the  two  bones,  and  of  the  brachialis  anticus  and 
biceps  in  pulling  the  upper  fragments  upward  and  forward. 


375 


THE    FOREARM.  377 

The  Forearm. 

The  surface  anatomy  and  markings  were  given  above.  The  skin  on 
the  anterior  surface  is  thin,  that  on  the  posterior  thicker  and  less  movable. 
In  the  subcutaneous  tissue  can  be  seen  on  the  anterior  surface  a  rich 
network  of  veins  and  lymphatics.  The  veins  form  one  large  trunk 
along  the  radial  border — the  radial  vein;  one  along  the  middle — the 
median;  and  a  third  along  the  ulnar  side — the  ulnar.  Their  relation 
to  each  other  at  the  elbow  has  been  given  under  the  anatomy  of  the 
elbow  region.  The  lymphatics,  which  are  most  marked  on  the  ulnar 
border  anteriorly,  pass  to  the  cubital  gland  (see  Fig.  106).  Those 
on  the  back  of  the  forearm  pass  across  to  the  front  of  the  elbow  at  the 
level  of  the  latter.  The  fascia  is  firmly  attached  to  the  posterior  border 
of  the  ulna  in  its  entire  length,  and  in  its  lower  third  to  the  outer  border 
of  the  radius,  thus  dividing  the  forearm,  with  the  aid  of  the  interosseous 
membrane,  into  two  compartments  in  its  lower  third  (see  Fig.  101). 
The  superficial  nerves  are  derived  from  the  external  and  internal 
cutaneous  (Fig.  103).  Of  the  muscles  of  the  forearm,  the  pronator 
radii  teres  may  be  strained  and  cause  a  painful  swelling  to  appear  in 
the  upper  third  of  the  anterior  aspect  of  the  arm.  The  tendon-sheaths 
of  the  extensors  of  the  thumbs  are  liable  to  become  inflamed,  causing 
a  swelling  to  appear  which  runs  obliquely  from  the  base  of  the  thumb 
across  the  back  of  the  lower  third  of  the  forearm,  giving  rise  at  first, 
upon  extension  of  the  thumb,  to  a  creaking  sensation  (Figs.  53  and  113). 

Arteries. — The  radial  and  ulnar  arteries  arise  from  the  brachial, 
just  below  the  elbow  (Fig.  96).  The  ulnar  lies  very  deep  below  the 
muscles  on  that  side  of  the  arm  above,  lying  a  little  more  superficially 
lower  down  (Fig.  99).  Just  above  the  wrist  it  lies  to  the  radial  side 
of  the  ulnar  nerve  and  tendon  of  the  flexor  carpi  radialis  (Fig.  101). 
Instead  of  arising  from  the  brachial  at  the  elbow,  it  may  be  given  off 
from  the  same  artery  in  the  arm,  or  even  arise  from  the  axillary.  It 
may  run  quite  superficial,  close  to  the  veins  of  the  elbow. 

The  radial  artery  also  arises  from  the  brachial,  passing  across  the 
pronator  radii  teres,  and  becomes  quite  superficial,  lying  to  the  radial 
side  of  the  flexor  carpi  radialis.  The  main  artery  may  pass  across  to 
the  back  of  the  thumb,  so  that  a  small  vessel  may  take  its  place  as  the 
one  felt  for  as  the  radial  pulse,  leading  to  deception  in  regard  to  its 
quality.  There  is  a  very  free  anastomosis  between  the  two  arteries 
on  the  front  of  the  forearm.  The  back  of  the  arm  is  but  scantily  sup- 
plied with  vessels.  Wounds  of  the  same  are  less  dangerous  and  it 
adapts  itself  well  for  the  administration  of  hypodermic  injections. 

Nerves. — The  ulnar  nerve  lies  to  the  inner  side  of  the  ulnar  artery 


378  UPPER    EXTREMITY. 

in  its  entire  course  (Figs.  94,  96,  and  99).  The  radial  nerve  lies  to  the 
radial  or  outer  side  of  the  same  artery.  The  median  nerve  passes 
between  the  two  heads  of  the  pronator  radii  teres,  lying  upon  the  deep 
flexors  until  just  above  the  wrist,  where  it  becomes  quite  superficial,  it  lies 
between  the  tendons  of  the  flexor  carpi  radialis  and  those  of  the  flexor  sub- 
limis,  and  is  very  likely  to  be  injured  here  (see  Figs.  96,  99,  101,  and  114). 

Fractures  of  the  Forearm.— The  most  frequent  seats  are  either 
in  the  middle  or  lower  thirds  of  the  bones  (Fig.  112).  They  may  be 
complete  or  incomplete  (greenstick).  Fracture  of  the  shaft  of  the 
ulna  usually  occurs  as  the  result  of  direct  violence,  and  on  account  of 
its  close  relation  to  the  skin,  the  fracture  is  often  compound.  Frac- 
tures of  the  shaft  of  the  radius  are  more  common  than  those  of  the 
ulna,  and  are  also  due  to  direct  violence.  When  the  fracture  is  above 
the  insertion  of  the  pronator  radii  teres,  the  upper  fragment  of  the 
radius  is  often  pulled  upward  by  the  biceps;  hence  in  such  cases  the 
arm  should  be  placed  in  a  supine  position.  In  other  fractures  of  one 
or  both  bones  the  arm  should  be  placed  midway  between  pronation  and 
supination,  the  bones  then  being  parallel,  and  the  space  between  them 
well  padded  in  order  to  prevent  the  pronators  pulling  them  toward  each 
other.  On  account  of  the  fact  that  the  bulk  of  the  blood  is  returned 
by  the  surface  veins  chiefly,  great  care  must  be  exercised  so  as  not  to 
apply  the  bandage  too  tightly,  cases  of  gangrene  having  been  reported. 

The  space  between  the  radius  and  ulna  is  greatest  when  the  arm  is 
held  in  a  position  midway  between  supination  and  pronation,  and  in 
this  position  the  radius  and  ulna  are  least  likely  to  become  adherent 
to  each  other.  A  study  of  figure  99  will  show  the  relations  at  the  upper 
third  of  the  forearm. 

The  Wrist  and  Hand. 

The  surface  anatomy  and  markings  have  been  given  on  page  347. 
The  skin  of  the  palm  of  the  hand  and  flexor  surfaces  of  the  fingers  is 
thick;  the  subcutaneous  tissue  is  composed  of  closely  arranged  bundles 
of  connective  tissue,  inclosing  lobuli  of  fat.  The  skin  on  the  back  of  the 
hand  is  much  thinner  and  the  subcutaneous  tissue  more  loosely  arranged. 
For  these  reasons,  swelling  due  to  injury,  infection,  or  general  diseases 
(nephritis)  shows  itself  more  readily  on  the  back  of  the  hand.  The 
palm  of  the  hand,  fronts  and  sides  of  the  fingers,  and  dorsal  aspects 
of  the  last  phalanges  all  show  an  absence  of  hair  and  sebaceous  glands; 
hence  furuncles  seldom  have  their  starting-point  here,  but  are  more 
frequent  on  the  dorsum  of  the  hand  and  of  the  first  and  second  rows 
of  phalanges,  where  there  are  numerous  hairs  and  sebaceous  follicles. 


Fig.  112. — Fracture  of  olecranon,  showing    how  upper  fragment  is  pulled  upward  by 
triceps.     Made  from  x-ray. 


379 


Digital  branch  of  radial  nerve 


Sheath   for    extensor   longus 
pollicis 


Extensor  carpi  radialis 
Extensor  longus  pollicis 

Annular  ligament 
(turned  back) 


Radial  nerve 


Bursa  over  proximal  in- 
terphalangeal  joint 


Metacarpophalangeal 
bursa 


Sheath  of  extensor  minimi  digiti 
Common  extensor  tendon-sheath 


Annular  ligament  (laid  back) 
Tendon-sheath  of  extensor  carpi 
ulnaris 


Fig.  113. — Dissection  of  back  of  hand  and  wrist. 


THE    WRIST   AND    HAND.  383 

In  the  subcutaneous  tissue  there  are  many  lymphatics,  nerves,  and 
blood-vessels.  On  the  back  of  the  hang!  the  veins  form  a  rich  super- 
ficial network;  over  the  palm  they  are  very  deeply  situated.  The 
lymphatics  on  the  flexor  surface  of  the  fingers  run  at  right  angles  from 
the  skin  toward  the  periosteum;  hence  infection  from  needle-pricks, 
etc.,  is  rapidly  carried  to  the  latter,  causing  a  felon  or  suppurative 
periostitis  (see  Fig.  117)  of  one  of  the  phalanges,  usually  the  most 
distal  or  ungual.  The  lymphatics  from  the  ulnar  side  of  the  hand 
accompany  the  ulnar  vein  to  the  elbow,  emptying  into  the  cubital 
and  axillary  glands  (Figs.  53  and  106);  those  from  the  radial  side  and 
back  part  of  the  hand  accompany  the  radial  veins  to  the  bend  of  the 
elbow,  emptying  partly  into  the  cubital,  but  chiefly  into  the  axillary 
glands  (Fig.  106).  For  these  reasons  a  lymphangitis  or  inflammation 
of  a  lymph-vessel  which  follows  an  infection  of  the  radial  side  of  the 
hand  travels  directly  to  the  axillary  glands,  while  on  the  ulnar  side  it 
travels  to  the  cubital. 

The  fascia  at  the  wrist,  both  in  front  and  behind,  forms  a  strong 
fibrous  band  (Figs.  113  and  114)  (annular  ligament)  which  arches  over 
the  carpus  beneath,  and  the  compartments  of  which  the  flexor  tendons 
run  on  the  front,  and  the  extensor  tendons  on  the  back  of  the  wrist 
(Fig.  101).  It  is  continuous  with  the  firm  fascia  of  the  palm  of  the 
hand  (palmar). 

The  Palmar  Fascia. — This  is  a  strong  fibrous  layer  firmly  attached 
to  the  skin  of  the  palm,  attached  above  to  the  annular  ligament.  Oppo- 
site the  metacarpo-phalangeal  joint  of  each  finger,  it  gives  off  two  slips 
which  are  attached  to  the  sides  of  the  joint  and  allow  the  flexor  tendons 
to  pass  between  them.  Between  the  slips  of  adjacent  fingers  lie  the 
digital  arteries  and  nerves.  The  palmar  fascia  in  diseased  conditions, 
especially  that  of  the  last  two  fingers  (Dupuytren's  contraction),  is  apt 
to  be  greatly  thickened,  causing  a  flexion  of  those  fingers.  On  account 
of  its  great  density,  it  prevents  pus  from  escaping  to  the  surface  and 
causes  it  to  escape  between  the  metacarpal  bones  toward  the  back  of 
the  hand,  or  along  the  tendon-sheaths  into  the  forearm.  Beneath  the 
fascia  lie  the  superficial  and  deep  palmar  arches  and  the  branches 
of  the  median  and  ulnar  nerves  (Figs.  96  and  114). 

Flexor  and  Extensor  Tendon-sheaths. — For  the  flexor  tendons 
we  may  speak  of  two  proximal  sheaths,  one  for  the  deep  and  superficial 
flexor  tendons  of  the  fingers  in  common  (Figs.  96,  101,  and  114),  which 
begins  about  i|  inches  above  the  annular  ligament,  passes  beneath  the 
same,  and  ends  about  the  middle  of  the  palm  of  the  hand ;  the  other  takes 
the  same  course,  but  incloses  only  the  flexor  longus  pollicis,  and  is  con- 


384  UPPER   EXTREMITY. 

tinuous  with  the  distal  portion  of  the  same.  The  distal  flexor  synovial 
sheaths  consist  of  one  for  each  finger,  extending  from  opposite  the  head 
of  the  metacarpal  bone  to  the  middle  of  the  last  phalanx  (Figs.  96  and 
114).  Those  for  the  index,  middle,  and  ring  fingers  communicate  with 
each  other,  while  that  for  the  little  finger  frequently  communicates 
with  the  common  flexor  sheath  in  the  palm  of  the  hand.  On  the  back 
of  the  hand  there  is  only  a  proximal  common  extensor  sheath,  beginning 
about  two  inches  above  the  wrist  and  extending  down  to  the  middle 
of  the  back  of  the  hand  (see  Figs.  53  and  113).  The  extensor  tendons 
on  the  back  of  the  fingers  have  no  tendon-sheath.  Infection  can 
travel  rapidly  along  the  lymphatics  of  the  flexor  or  front  surface  of  the 
fingers,  penetrate  the  tendon- sheaths,  and  pass  to  the  palm  of  the  hand. 
In  infection  of  the  thumb  and  little  finger  organisms  can  travel  direct  to 
the  forearm,  giving  rise  to  serious  intermuscular  phlegmons.  These 
sheaths  may  be  the  seat  of  a  tubercular  inflammation,  giving  rise  to 
fluctuating  swellings  along  their  normal  situation.  The  nails  receive 
their  nourishment  chiefly  at  the  matrix  or  base  of  each  nail,  and  if 
this  is  injured,  the  entire  distal  portion  of  the  nail  is  destroyed. 

Wrist-joint. — Its  strength  depends  mainly  upon  the  strong  tendons 
which  surround  it  and  also  the  strong  ligaments  which  bind  the  carpal 
bones  together.  It  is  rarely  dislocated,  and  if  so,  the  posterior  form  is 
more  common,  on  account  of  the  greater  strength  of  the  anterior  ligament 
and  the  fact  that  dislocation  occurs  through  a  fall  upon  the  outstretched 
hand.  Effusion  due  to  disease  of  the  joint  shows  itself  by  a  swelling 
on  the  back  of  the  wrist  (Fig.  53),  and  is  apt  to  extend  to  the  intercarpal 
joints  and  to  the  adjacent  tendon-sheaths.  A  circumscribed  swelling, 
commonly  called  ganglion,  or  weeping  sinew,  may  appear  at  the  back 
of  the  wrist,  or  even  on  the  front  of  the  same,  or  along  any  of  the  tendon- 
sheaths.  It  is  usually  a  hernial  protrusion  from  the  tendon-sheath,  or  a 
similar  condition  of  the  synovial  membrane  of  the  wrist-joint.  The  ana- 
tomic fact  that  these  ganglia  communicate  frequently  with  the  wrist- 
joint  should  be  borne  in  mind;  it  should  also  be  remembered  that  they 
are  frequently  tubercular,  so  that  an  indiscriminate  scattering  of  the 
same  by  means  of  a  book,  etc.,  as  recommended  by  some,  may  be 
followed  by  a  serious  tuberculosis  of  the  wrist-joint  on  account  of  this 
communication.  An  inflammation  of  the  tendon-sheaths  may  be  either 
of  an  acute  or  a  chronic  nature.  If  acute,  it  gives  rise  to  pain  and 
swelling  along  the  line  of  the  tendon-sheath,  and  often  to  a  sensation 
of  crepitation  (tendo-vaginitis-crepitans).  Such  inflammations,  both 
acute  and  chronic,  are  likely  to  appear  in  those  who  use  the  hands 
extensively — artists,  pianists,  machinists,  etc.  The  relation  of  the 


Digital  branches  of  ul- 
nar  artery  and  nerve 


Superficial  palmar  arch 


Digital  branch  of  radial 
nerve 


Fig.  114. — Dissection  of  front  of  hand.  2,  Median  nerve.  4,  Flexor  carpi  radialis 
tendon.  5,  Superficial  and  deep  flexor  tendons.  6,  Flexor  carpi  ulnaris  tendon.  7, 
Annular  ligament  turned  back.  U,  Ulnar  artery  lying  upon  ulnar  side  of  flexor  carpi 
ulnaris  tendon  (6).  Upon  its  inner  (ulnar)  side  lies  the  ulnar  nerve  (white  band).  R, 
Radial  artery,  lying  on  radial  side  of  flexor  carpi  radialis  tendon  (4).  Upon  its  outer 
side  lies  the  radial  nerve. 


3*5 


Upward  displacement  of 
hand    and  distal  or  lower  -  -  -  A  I 

fragment 


Lower  fragment 
Upper  fragment 


1 


Line  of  fracture 


Prominence  at  front  of 

wrist 


Fig.    115. — Colles'    fracture.     Lateral   view.     Showing   upward   displacement   of   lower 
fragment,  giving  rise  to  silver-fork  deformity.     Made  from  x-ray  picture. 


387 


Displacement  of 
hand  and  lower 
fragment  to  radial 
side 


Lower  fragment  of 
radius 


Upper  fragment- 


Displacement  of 
forearm  and  upper 
fragment  to  ulnar 
side 


Fig.  1 1 6. — Colics'  fracture.     View  from  above,  showing  displacement  of  lower  fragment 
and  hand  toward  radial  side.     Made  from  x-ray  picture. 


389 


PARALYSIS    OF    THE    NERVES    OF    THE    BRACHIAL  PLEXUS.  391 

tendons  and  vessels  at  the  front  and  back  of  the  wrist  to  each  other 
can  be  best  understood  by  a  study  of  figure  101. 

Colics'  Fracture.— This  is  a  fracture  of  the  lower  end  of  the  radius, 
occurring  in  adults  about  one  inch  above  the  articular  surface  (Figs. 
115  and  116).  In  children  an  incomplete  fracture  may  exist  at  about 
the  same  point,  due  to  separation  of  the  lower  epiphysis  of  the  radius 
(see  Fig.  102).  Colics'  fracture  is  usually  transverse  and  due  to  falls 
upon  the  outstretched  hand.  There  may  be  great  displacement  of  the 
lower  fragment,  usually  upward  and  outward,  with  displacement  of  the 
upper  fragment  and  entire  ulnar  side  of  the  arm  down  and  inward,  so 
that  the  hand  is  carried  to  the  radial  side  and  backward.  The  ulna 
is  more  prominent  in  front  of  the  wrist  and  to  its  inner  side. 

The  superficial  palmar  arch,  as  well  as  the  deep  palmar  arch,  lie 
within  the  limits  of  a  letter  M  which  the  creases  on  the  palm  of  the 
hand  form  (see  Fig.  96).  The  ulnar  and  median  nerves  also  lie  here 
(Fig.  114),  giving  off  their  digital  branches  to  run  along  the  lateral 
aspect  of  each  finger.  Incisions  to  relieve  suppuration  in  the  fingers 
should,  if  possible,  be  made  midway  between  the  tendon-sheath  and 
the  lateral  aspect  of  the  fingers,  so  as  to  avoid  opening  the  sheath  and 
injuring  the  digital  nerves  and  vessels. 

Paralysis  of  the  Nerves  of  the  Brachial  Plexus. 

i .  Posterior  Circumflex. — The  effect  of  a  paralysis  of  this  nerve  was 
spoken  of  in  relation  to  fractures  of  the  surgical  neck  of  the  humerus  (see 


Fig.  117. — Cross-section  of  finger  (diagrammatic).  F,  Flexor  tendon  in  sheath. 
D,  Extensor  tendon.  The  digital  nerve  and  artery  are  seen  lateral  to  the  bone.  Note 
the  arrangement  of  connective  tissue  on  palmar  and  dorsal  surfaces,  at  right  angles  to 
bone  in  former. 

Fig.  1 08).  The  resulting  inability  to  use  the  deltoid  renders  it  impossible 
for  the  patient  to  raise  (abduct)  the  arm,  and  causes  a  rapid  atrophy  of 
the  fibers  of  the  muscle  (loss  of  normal  convex  outline  of  shoulder). 


392  UPPER   EXTREMITY. 

2.  Musculospiral  and  its  Continuation  (Radial  and  Posterior 
Interosseous). — This  has  been  referred  to  in  relation  to  fractures  of  the 
middle  of  the  shaft  of  the  humerus  (see  Fig.  no).     In  addition  to  its  fre- 
quent injury  in  fractures  at  this  point,  it  is  also  paralyzed  as  the  result  of 
pressure  of  the  head  upon  the  nerve  over  the  outer  condyle  during  deep 
sleep  (especially  in  alcoholics).     Another  frequent  cause  of  paralysis  of 
this  nerve  is  lead-poisoning,  producing  one  of  its  most  striking  symp- 
toms (Fig.  118),  known  as  "drop- wrist."     In  paralysis  of  this  nerve  the 
following  movements  cannot  be  carried  out: 

MOVEMENTS  LOST.  MUSCLES  PARALYZED. 

(a)  Extension  of  forearm,  i.  e.,  of  elbow-       Triceps. 

joint. 

(b)  Flexion   of    elbow  when   midway    be-       Supinator  Longus. 

tween  supination  and  pronation. 

(c)  Supination  of  forearm.  Supinator  Brevis. 

(d)  Extension  of  wrist  (raising  it).  Extensor  Carpi  Radialis  longus  et  brevis. 

Extensor  Carpi  Ulnaris. 

(e)  Extension  of  fingers.  Extensor  Communis  Digitorum. 
(/)    No  extension,  and  only  imperfect  ad-       Extensor  Pollicis  longus  et  brevis. 

duction  of  thumb. 

In  addition,  there  is  rapid  atrophy  of  the  (back  of  the  forearm)  extensor 
muscles,  and  anesthesia  of  the  posterior  aspect  of  the  arm,  forearm,  and 
thumb,  index-finger  and  outer  margin  of  middle  finger  (see  Fig.  103). 

3.  Paralysis  of  the  ulnar  nerve  is  a  frequent  accompaniment  of 
progressive  muscular  atrophy.     It  causes  a  characteristic  deformity  of 
the  hand,  known  as  the  "claw  hand"  (main  en  griffe),  shown  in  figure 
1 19.     The  following  movements  cannot  be  carried  out : 

MOVEMENTS  LOST.  MUSCLES  PARALYZED. 

(a)  Adduction  of  hand,  i.  e.,  toward  ulnar  Flexor  Carpi  Ulnaris. 

side. 

(6)   Flexion  of  fingers,  especially  little.  Flexor  Profundus  Digitorum. 

(c)  Flexion    of  first   phalanges   of  fingers  Interossei  and  Lumbricales. 

and   extension  of  middle   and  end 
phalanges. 

(d)  Adduction  of  thumb.  Adductor  Pollicis. 

The  claw-hand  deformity  is  due  to  the  fact  that  the  antagonists  of  the 
interossei  and  lumbricales,  the  extensors  and  flexors  (when  nerve  is  af- 
fected in  forearm  after  nerve  for  flexors  has  been  given  off),  extend  the 
first  and  flex  the  middle  and  end  phalanges  (see  Fig.  119). 

These  paralyses  of  motion  are  accompanied  by  anesthesia  of  the 
ulnar  side  of  the  palmar  and  dorsal  surfaces  of  the  hand  and  little  finger, 
and  ulnar  half  of  the  middle  finger  (see  Fig.  119). 


Fig.  118. — Drop-wrct  following  paralysis  of  the  musculospiral  nerve  (Leube). 


393 


Fig.  119. — Claw-hand  (main  en  Griffe)  following  ulnar  paralysis  (Leube).     (See  text.) 


395 


PARALYSIS   OF   THE    NERVES   OF   THE   BRACHIAL  PLEXUS. 


397 


4.  Paralysis  of  the  Median  Nerve.— 


MOVEMENTS  LOST. 

(a)  Inability  to  pronate  forearm. 

(b)  Abduction    of    hand     (bending    it   to 

radial  side). 

(c)  Flexion  of  end  phalanges  (index  and 

middle  finger  ). 

(d)  Flexion   of    middle    phalanges   of   all 

fingers. 

(e)  Flexion  and  abduction  of  thumb. 


MUSCLES  PARALYZED. 
Pronator  Radii  Teres  and  Pronator  Quad- 

ratus. 
Flexor  Carpi  Radialis. 

Flexor  Profundus  Digitorum  (outer  half). 

Flexor  Sublimis  Digitorum. 

Abductor  pollicis  and  Opponens  pollicis. 


These  are  accompanied  by  anesthesia  of  the  palmar  surface  of  the 
thumb,  index,  middle,  and  radial  side  of  the  ring  fingers  (see  Fig.  103). 

Combinations  of  these  paralyses  can  exist  after  any  injury  to,  or  pres- 
sure upon,  the  brachial  plexus,  such  as  dislocation  of  shoulder,  tumors, 
obstetric  (Duchenne,  Erb)  paralysis,  etc.,  or  in  spinal  cord  diseases. 


398  LOWER    EXTREMITY. 


LOWER  EXTREMITY. 

Examination  during  Life. — Note  the  division  (arbitrarily  made)  of 
the  lower  extremity  into  the  buttock,  or  hip  region,  the  thigh,  the  leg, 
and  the  foot.  The  hip  region  extends  from  the  crest  of  the  ilium  to  the 
glutcal  fold  (see  Fig.  117).  The  thigh  region  embraces  the  greater  part 
of  the  femur  and  its  surrounding  structures,  from  the  inguinal  folds  in 
front  and  gluteal  fold  behind  to  the  knee.  The  leg  includes  all  of  the 
lower  extremity  between  the  knee  and  the  ankle.  The  foot  includes  all 
between  the  ankle-joint  and  the  ends  of  the  toes. 

1.  Palpate  and  mark  with  a  dermatographic  pencil  the  following 
landmarks:  Anterior  and  posterior  superior  spinous  .processes  of  the 
ilium,  great  trochanter,  tuberosity  of  ischium,  lower  borders  of  inner  and 
outer  condyles  of  femur,  middle  of  patella,  upper  borders  of  inner  and 
outer  tuberosities  of  the  tibia,  tubercle  of  tibia,  head  of  fibula,  lower 
borders  of  inner  and  outer  malleoli. 

2.  Take  a  steel  tape-measure  and,  with  the  person  to  be  examined 
lying  upon  the  opposite  side,  mark  out  the  Roser-Nelaton  line.     It  is  the 
line  connecting  the  anterior  superior  spine  of  the  ilium  with  the  tuber- 
osity of  the  ischium  (see  Figs.  118  and  85),  and  passes  along  the  upper 
border  of  the  greater  trochanter,  the  latter  being  usually  referred  to,  as 
will  be  done  here,  as  the  trochanter.     In  fractures  of  the  neck  of  the 
femur,  or  in  dislocations  of  the  hip,  this  relation  of  the  above  three  bony 
points  is  changed  (see  below7),  the  trochanter  then  being  above  the  line. 

3.  With  the  person  to  be  examined  lying  upon  his  back,  drop  a  line 
vertically  downward  from  the  anterior  superior  spine  of  the  ilium.     Mark 
a  second  oblique  line  from  the  latter  point  to  the  upper  border  of  the 
trochanter,  and  a  third  horizontal  line*  from  the  trochanter  to  join  the 
first- mentioned  vertical  line.     These  three  lines  form  Bryant's  triangle, 
which  is  also  a  standard  measurement  in  hip  injuries  (see  below). 

4.  Note  the  position  of  the  gluteal  fold;  the  lower  border  of  the 
gluteus  maximus  lies  a  little  above  it.     Also  palpate  the  firm  band  (ilio- 
tibial)  of  fascia  lata  (tensor  fasciae  femoris  muscle)  w^hich  extends  from 
the  ilium  to  the  trochanter  and  is  relaxed  in  fractures  of  the  neck  of  the 
femur. 

5.  Draw  a  line  with  the  steel  measure  (when  the  limbs  are  adducted) 
from  the  anterior  superior  spine  through  the  middle  of  the  patella  to  the 
lower  border  of  the  inner  malleolus  (see  Fig.  122).     Compare  this  with 
the  same  measurement  of  the  opposite  limb.     There  is  at  times  a  differ- 
ence of  one-fourth  to  one-half  inch  under  normal  conditions,  the  right 


Fig.  120. — Principal  superficial  and  deep  lymphatics  on  anterior  surface  of  extremities 
and  trunk,  i,  Supraclavicular.  2,  Axillary.  3,  Cubital.  4,  Bronchial.  5,  Anterior 
mediastinal.  On  the  right  side  these  are  seen  below  the  bronchial,  communicating  with 
7,  those  of  the  liver  (see  Fig.  54).  6,  Anterior  intercostal.  8,  Plexus  of  lymphatics  around 
celiac  axis,  receiving  the  lymph  from  the  principal  solid  abdominal  viscera.  9,  Lumbar 
lymphatics,  which  receive  the  lymph  from  10,  the  deep  iliac  lymphatics,  and  also  those 
from  the  pelvis,  n,  Superficial  inguinal  lymphatics,  which  receive  the  lymph  from  the 
lower  half  of  the  back  and  abdomen,  and  from  the  external  genitals,  and  lower  portion  of 
the  rectum  and  vagina.  12,  Inguinal  lymphatics  over  saphenous  opening,  which  receive 
the  lymph  from  the  lower  extremity,  and  occasionally  from  the  external  genitalia.  In  this 
figure  the  superficial  lymphatics  are  shown  as  a  hollow  circle,  the  deep  ones  as  a  solid  one. 
13,  Location  of  swelling  in  effusion  into  shoulder-joint.  14,  Same  of  knee-joint. 

399 


Fig.  121. — Surface  markings  of  thoracic  and  abdominal  viscera  viewed  from  the  left 
side;  also  view  of  Roser-Nelaton  line.  C.C.,  Costo-clavicular  line.  Ax,  Mid-axillary  line. 
U.L.,  Upper  lobe  of  lung.  L.L.,  Lower  lobe.  2,  Lower  margin  of  lung.  3,  Lower  margin 
of  pleura.  4,  Anterior  superior  spine  of  ilium.  5,  Costal  arch.  S,  Spleen.  T.C.,  Trans- 
verse colon.  D.C.,  Descending  colon.  S.F.,  Sigmoid  flexure  (iliac  colon).  R.N.,  Roser- 
Nelaton  line  passing  from  4  across  top  of  trochanter  major  (T)  to  tuberosity  of  ischium 
(Is.). 


401 


EXAMINATION   OF    LOWER    EXTREMITY    DURING    LIFE.  403 

being  shorter  than  the  left  (see  below).  These  measurements  are  of  the 
greatest  value  in  order  to  determine  shortening  due  to  injuries  or  dis- 
eases. 

6.  Palpate  the  powerful  quadriceps  extensor  muscle  on  the  front 
of  the  thigh,  and  observe  how  its  aponeurosis  passes  around  and  over 
the  patella  and  is  continued  below  the  latter  as  the  strong  ligamentum 
patellae  to  the  tubercle  of  the  tibia.     The  ligament  is  best  felt  when 
the  knee  is  slightly  flexed. 

7.  Note  the  movements  of  the  hip- joint — adduction  and  abduction 
(see  Figs.  122  and  123),  flexion  (Fig.  127),  extension,  internal  and  ex- 
ternal rotation. 

8.  Palpate  the  adductor  muscles  at  the  inside  of  the  thigh  and  the 
hamstring  (outer  and  inner)  tendons  at  the  back  of  the  knee.     Between 
the  latter,  close  to  the  lower  end  of  the  femur,  the  popliteal  space  begins. 
The  gracilis,  semimembranosus  and  semitendinosus  (the  inner  ham- 
string), and  the  biceps  (outer  hamstring)  cause  flexion  of  the  knee-joint. 

9.  Mark  the  sides  of  Scarpa's  triangle  (Poupart's  ligament,  inner 
border  of  the  sartorius  and  outer  border  of  adductor  longus) ;  in  it  the 
pulsations  of  the  femoral  artery  can  be  felt. 

10.  Palpate  the  lymphatic  glands  lying  above  and  below  Poupart's 
ligament;  those  above  it  drain  the  external  genitalia  and  anus;  those 
below  it  drain  the  lower  extremities  (see  Figs.  117  and  121). 

1 1 .  Palpate  the  condyles  of  the  femur  and  the  tuberosities  of  the  tibia. 
Note  the  movements  of  the  knee-joint — flexion  (see  Fig.  122),  extension, 
and  some  external  and  internal  rotation.     Note  the  furrows  or  depres- 
sions on  either  side  of  the  patella ;  they  are  obliterated  in  effusions  into 
the  knee-joint  (Fig.  122). 

12.  Measure  the  length  of  the  shaft  of  the  femur  from  the  upper 
border  of  the  trochanter  to  the  lower  border  of  the  outer  condyle.     Com- 
pare it  with  the  opposite  femur. 

13.  Measure  the  lengths  of  the  tibiae  from  the  upper  border  of  the 
inner  tuberosity  to  the  lower  border  of  the  inner  malleolus  (Fig.  122). 
Also  measure  the  fibulae  from  the  upper  border  of  the  head  to  the  lower 
border  of  the  outer  malleolus. 

14.  Mark  on  the  surface  the  lines  of  the  epiphyseal  cartilages  (ac- 
cording to  Fig.  125)  of  the  femur,  tibia,  and  fibula. 

15.  Palpate  the  anterior  border  and  surface  (shin)  of  the  tibia  as  far 
down  as  the  outer  malleolus;  the  remainder  of  the  tibia  is  covered  by 
muscles.     Palpate  the  fibula;  only  the  head,  lower  third  of  the  shaft, 
and  the  external  malleolus  can  be  felt. 

1 6.  Palpate  and  note  the  actions  of  the  extensor  and  peroneal  mus- 


404  LOWER   EXTREMITY. 

cles,  which  cause  a  fullness  on  the  outer  upper  aspect  of  the  leg.  The  ex- 
tensors (longus  digitorum  and  proprius  hallucis)  extend  the  toes — i.  e., 
bend  them  upward- — and  flex  the  ankles  (Fig.  127).  The  peroneal 
muscles  (longus  and  brevis)  raise  the  outer  border  of  the  foot.  When 
paralyzed,  as  in  infantile  spinal  paralysis,  this  outer  border  of  the  foot 
droops  and  cannot  be  raised  (paralytic  club-foot). 

17.  Palpate  the  large  muscles  of  the  calf  (soleus  and  gastrocnemius) 
to  their  tendon  (tendo  Achillis)  inserted  into  the  calcaneus.     Note  their 
action:  they  flex  the  knee  and  extend  the  foot  (Fig.  127). 

1 8.  Note  the  action  of  the  tibialis  anticus  and  posticus.     They  lie  on 
the  inner  side  of  the  tibia  and  raise  the  inner  border  of  the  foot. 

19.  The  movements  of  the  ankle-joint  are  flexion,  extension,  inver- 
sion, and  eversion  (Fig.  127).     Flexion  is  produced  by  the  tibialis  anticus 
and  the  extensors  chiefly.     Extension  is  effected  chiefly  by  the  muscles 
of  the  calf — the  tibialis  posticus,  peroneal  muscles,  and  flexors.     Inver- 
sion— that  is,  raising  the  inner  border  of  the  foot — is  produced  by  the 
tibialis  anticus  and  posticus.     Eversion  (raising  the   outer  border  of 
the  foot)  is  produced  by  the  peroneal  muscles. 

20.  Palpate  the  posterior  tibial  artery  behind  the  inner  malleolus 
(Fig.  123). 

21.  Palpate  the  malleoli.     The  tip  of  the  external  is  situated  one- 
fourth  of  an  inch  lower  and  three-fourths  of  an  inch  further  back  than 
that  of  the  internal  malleolus. 

22.  Palpate  the  depressions  in  front  of  and  behind  the  malleoli.     In 
effusions  into  the  ankle-joint  these  are  obliterated. 

23.  On  the  foot  palpate  the  tubercle  of  the  scaphoid  just  below  and 
in  front  of  the  internal  malleolus. 

24.  Palpate  the  tuberosity  of  the  calcaneus  into  which  the  tendo 
Achillis  is  inserted.     Also  palpate  the  joint  between  the  internal  cunei- 
form and  first  metatarsal  bones  on  the  inner  side  of  the  foot,  and  the  joint 
between  the  cuboid  and  the  metatarsal  of  the  little  toe.     Note  the  action 
at  the  metatarso-phalangeal  joint,  which  consists  in  flexion,  extension, 
some  abduction,  and  adduction — that  is,  from  and  to  the  middle  line 
of  the  second  toe. 

25.  Observe  the  action  of  the  toes,  flexion  and  extension.     Mark 
out  a  line  from  the  tubercle  of  the  tibia  to  a  point  midway  between  the 
two  malleoli  on  the  anterior  surface.     This  constitutes  the  axis  of  the  leg 
(see  Fig.  122),  and,  when  prolonged  from  this  latter  point  (midway  be- 
tween the  two  malleoli)  in  front,  extends  to  the  interspace  between  the 
two  toes. 

26.  Measure  the  circumference  of  the  thighs  and  of  the  calves  of  leg 
on  each  side  (Fig.  127). 


Fig.  122. — Lines  of  measurement  of  lower  extremities  and  angle  of  abduction  of  the 
hip-joint.  The  left  leg  is  seen  in  the  position  of  maximum  abduction.  The  line  of  meas- 
urement of  the  lower  extremity  usually  taken  from  anterior  superior  spine  of  ilium  (A), 
through  middle  of  patella,  to  the  lower  border  of  the  inner  malleolus  (B)  is  shown.  In 
the  leg,  under  normal  conditions,  the  true  axis  of  the  leg  and  foot  is  a  line  drawn  from  C 
(middle  of  the  patella)  to  a  point  D,  midway  between  the  two  malleoli  and  terminating 
at  E,  which  is  the  base  of  the  interspace  between  the  great  and  second  toes.  The  length 
of  the  tibia  can  be  measured  from  a  point,  F,  the  upper  border  of  the  inner  tuberosity,  to 
the  lower  border  of  the  internal  malleolus. 


405 


Fig.  123. — Angle  of  adduction  of  the  hip-joint;  tendon-sheaths  around  ankle-joint 
on  front  and  inner  side  of  foot  and  patellar  bursae.  i,  Tendon-sheath  of  tibialis  anticus. 
2,  Tendon-sheath  of  the  extensor  hallucis  longus.  3,  Common  tendon-sheath  of  the  ex- 
tensor longus  digitorum.  4,  Tendon-sheath  of  the  tibialis  posticus,  behind  which  lies 
a  short  tendon-sheath  for  the  flexor  longus  digitorum  and  flexor  hallucis  longus.  5, 
Prepatellar  bursa.  6,  Bursa  between  the  insertion  of  the  ligamentum  patellae  and  tubercle 
of  the  tibia.  7,  Angle  of  adduction  of  the  hip-joint. 


407 


Fig  124.— Posterior  view  of  lymphatics  of  trunk  and  extremities,  also  tendon-sheaths, 
bursa?,  and  joint-effusion  areas  on  back  of  arm  and  leg.  i,  Subscapular  lymphatics.  2, 
Posterior  mediastinal  lymphatics,  projected  on  surface  of  body.  3,  Posterior  intercostal 
lymphatics.  4,  Popliteal  lymphatics.  5,  Gluteal  fold.  6,  Position  of  trochanteric  bursa. 
7,  Position  of  bursa  on  gastrocnemius  muscle  (inner  head).  8,  Metacarpophalangeal 
bursae.  9,  Common  tendon-sheath  of  the  extensors  of  the  middle,  ring,  and  little  fingers. 
10  and  u,  Extensor  tendon-sheaths  of  the  thumb,  which  are  frequently  affected  in  tendo- 
vaginitis  crepitans.  12,  Location  of  swelling  in  elbow-joint  effusion.  13,  Subdeltoid 
bursa.  14,  Location  of  sacro-iliac  joint  (right). 

409 


Fig.  125. — Epiphyses  in  boy,  aged  six.  i,  Upper  epiphysis  of  humerus.  2,  Shaft 
of  humerus.  3,  Lower  epiphysis  of  humerus.  4,  Upper  epiphysis  of  ulna.  5,  Shaft 
of  ulna.  6,  Lower  epiphysis  of  ulna.  8,  Shaft  of  radius,  above  which  is  the  upper  epi- 
physis. 9,  Lower  epiphysis  of  radius.  10,  Anterior  superior 'spine  of  ilium,  n,  Head 
of  femur,  showing  epiphyseal  line  joining  it  to  the  neck.  12,  Greater  trochanteric  epi- 
physis. 13,  Shaft  of  femur.  14,  Lower  epiphysis  of  femur.  15,  Upper  epiphysis  of 
tibia.  16,  Shaft  of  tibia.  18,  Lower  epiphyses  of  tibia  and  fibula.  19,  Shaft  of  fibula, 
above  which  is  the  upper  epiphysis  of  the  fibula. 


26 


411 


Fig.  126.— Surface  markings  on  back  of  leg.  i,  Sciatic  nerve.  2,  Posterior  tibial 
nerve.  3,  Peroneal  nerve.  4,  Popliteal  artery.  5,  Posterior  tibial  artery  accompanied 
by  the  posterior  tibial  nerve  (?).  6,  Peroneal  artery. 


4IJ 


Fig.  127. — Movements  of  joints  of  lower  extremity,  showing  the  angles  of  maximum 
flexion  of  the  hip-,  knee-,  and  ankle-joints  at  i,  2,  and  3,  respectively,  and  the  angle 
of  maximum  extension  of  the  ankle-joint  at  4.  5,  6,  and  7,  Best  points  to  measure 
circumference  of  thigh,  knee,  and  calf. 


415 


SURFACE   MARKINGS   OF   LOWER   EXTREMITY.  417 

Surface  Markings  of  Lower  Extremity.— i.  The  course  of  the 
femoral  artery  and  vein  corresponds  to  a  line  extending  from  a  point 
midway  between  the  anterior  superior  spine  of  the  ilium  and  the  sym- 
physis  pubis  to  the  internal  condyle  (upper  and  back  part).  The  artery 
lies  on  the  anterior  aspect  of  the  leg  in  the  upper  third  of  this  line  (see 
Fig.  128),  on  the  internal  aspect  (Hunter's  canal)  in  a  little  more  than 
its  middle  third,  and  more  toward  the  posterior  aspect  in  its  lower 
third. 

2.  Femoral  vein.    Same  line  as  for  the  femoral  artery,  lying  to  its 
inner  side  above  and  outer  side  below  (Fig.  128). 

3.  Anterior  crural  nerve  accompanies  femoral  artery  and  vein  in 
its  upper  third  (Fig.  128). 

4.  The  popliteal  artery  corresponds  to  a  line  drawn  along  the 
middle  of  the  back  of  the  thigh  from  the  junction  of  its  lower  and  middle 
thirds  (upper  end  of  popliteal  space)  almost  vertically  downward  to  a 
point  corresponding  to  the  level  of  the  tubercle  of  the  tibia  in  front  (Figs. 
1 26  and  1 28) .    The  popliteal  vein  lies  to  its  outer  side  above,  but  opposite 
the  knee-joint  lies  at  a  more  posterior  level,  that  is,  more  superficially. 

5.  The  posterior  tibial  artery  corresponds  to  a  line  drawn  from 
the  middle  of  the  posterior  aspect  of  the  leg,  at  the  level  of  the  tubercle 
of  the  tibia,  to  a  point  midway  between   the  internal  malleolus  and 
tendo  Achillis  (Fig.  126). 

6.  The  peroneal  artery  lies  at  a  deeper  level  than  the  posterior 
tibial.     Its  upper  point  on  the  surface  is  the  same  as  that  of  the  pos- 
terior tibial;  that  is,  it  is  given  off  about  three  inches  below  the  head 
of  the  fibula,  and  a  line  from  this  point  to  one  between  the  external 
malleolus  and  tendo  Achillis  corresponds  to  its  course  (Fig.  126). 

7.  The  anterior  tibial  artery  corresponds  to  a  line  drawn  from  a 
point  two  inches  below  the  tubercle  of  the  tibia,  on  the  anterior  aspect  of 
the  leg,  to  a  point  midway  between  the  two  malleoli  on  the  front  of  the 
ankle-joint.     In  its  entire  course  it  lies  between  the  tibia  and  fibula 
until  its  lower  third,  where  it  lies  in  front  of  the  tibia  (Fig.  128). 

8.  The  external  or  short  saphenous  vein  corresponds  to  a  line 
from  the  outer  side  of  the  tendo  Achillis  along  the  posterior  aspect  of  the 
leg,  to  a  point  opposite  the  knee-joint  (Fig.  51). 

9.  The  internal  or  long  saphenous  vein  (see  Figs.  130  and  132) 
corresponds  to  a  line  from  the  internal  malleolus,  along  the  inner  border 
of  the  leg  and  thigh,  to  Scarpa's  triangle,  close  to  Poupart's  ligament. 
The  saphenous  opening  is  situated  i  J  inches  below  and  external  to  the 
pubic  spine. 

10.  The  great  sciatic  nerve  corresponds  to  a  line  drawn  from  a 


41 8  LOWER    EXTREMITY. 

point  midway  between  the  tuberosity  of  the  ischium  and  great  trochanter 
and  continued  downward  along  the  back  of  the  thigh  to  the  center  of  the 
popliteal  space,  that  is,  opposite  the  knee-joint  (Fig.  126). 

11.  External  popliteal  nerve,  or  peroneal  nerve,  extends  from 
the  above  point  of  division  of  the  great  sciatic  behind  the  head  of  the 
fibula,  and  runs  parallel  to  the  peroneal  artery  as  given  above  (Fig.  126). 

12.  The  anterior  and  posterior  tibial  nerves  accompany  the 
arteries  of  the  same  name  (Figs.  126  and  128). 

Buttock  or  Hip  Region. 

The  boundaries  of  this  region,  also  called  the  gluteal  region,  are  the 
crest  of  the  ilium  (along  its  entire  length)  above,  the  gluteal  fold  below. 
This  fold  is  a  little  above  the  lower  border  of  the  gluteus  maximus,  and 
is  formed  by  a  thickening  of  the  fascia  lata  at  this  point.  Under  normal 
conditions  the  hip  region  is  rounded  and  full  and  the  gluteal  fold  well 
marked.  In  disease  of  the  hip-joint  (tuberculosis)  the  fullness  disap- 
pears, owing  to  atrophy  of  the  muscles,  and  the  gluteal  fold  is  obliterated. 
In  general  emaciation  the  large  amount  of  fat  beneath  the  skin  of  this 
region  (see  Fig.  89)  is  absorbed  and  the  fullness  of  the  buttock  is  re- 
placed by  a  concavity  or  hollow. 

The  skin  of  this  region  is  quite  coarse  and  thick.  It  is  a  frequent 
seat  of  furuncles,  which  resemble  those  upon  the  back  of  the  neck  in 
hardness,  owing  to  the  dense  infiltration  of  the  tissues.  The  subcuta- 
neous fat  is  very  abundant  (see  Fig.  89),  so  that  even  in  moderately  nour- 
ished individuals  there  is  a  considerable  space  containing  fat  between 
the  gluteus  maximus  and  the  skin. 

The  fascia  lata  separates  the  muscles  of  the  region  from  the  skin  and 
fat.  It  is  a  powerful  structure  and  gives  a  strong  point  of  attachment  for 
the  muscles  of  the  thigh.  It  begins  at  the  crest  of  the  ilium,  and  from 
this  point  to  the  outer  tuberosity  of  the  tibia  forms  an  especially  strong 
band  of  connective  tissue — the  iliotibial.  It  is  continuous  around  the 
entire  thigh,  so  that  pus  beneath  it  can  spread  rapidly  in  all  directions. 
It  also  sends  in  prolongations  between  the  muscles  of  the  hip  and  thigh 
regions,  separating  them  from  each  other,  as  will  be  referred  to  later. 

In  fractures  of  the  neck  of  the  femur  (see  Fig.  136)  one  of  the  earliest 
and  most  characteristic  signs  is  the  relaxation  of  the  tense  fascia  lata,  ex- 
tending from  the  crest  of  the  ilium  to  the  trochanter. 

The  muscles  of  the  hip  or  buttock  act  chiefly  as  abductors  and  ex- 
ternal rotators  of  the  lower  extremity.  In  the  early  stages  of  hip-joint 
disease  the  reflex  spasm  of  these  muscles  limits  the  motion  at  the  hip, 
and  they  cause  abduction  and  outward  rotation  (flexion  being  produced 


Fig.  128. — Surface  markings  of  blood-vessels  and  nerves  on  anterior  surface  of  lower 
extremity,  i,  Surface  marking  of  external  iliac  artery  and  vein.  2,  Surface  marking  of 
femoral  artery.  2',  Projection  of  popliteal  artery  on  anterior  surface  of  thigh.  3,  Anterior 
crural  nerve.  4,  Femoral  vein.  4',  Projection  of  popliteal  vein  on  anterior  surface  of  thigh. 
5,  Anterior  tibial  artery  surface  markings.  6,  Surface  marking  of  anterior  tibial  nerve.  7 
and  8,  Show  the  relation  (on  the  posterior  aspect  of  the  femur)  of  the  popliteal  artery  (7) 
and  vein  (8)  to  a  frequent  seat  of  fracture  (9)  above  the  condyle  of  the  femur,  showing 
how  the  lower  fragment  can  be  pulled  down  by  gastrocnemii  muscles  and  compress  these 
vessels.  P,  Psoas  muscle,  or  rather  iliopsoas  muscle,  along  which  cold  abscesses  travel 
from  the  dorsolumbal  junction  of  the  spine,  within  the  sheath  of  this  muscle,  and  appear 
externally  at  the  saphenous  opening,  close  to  the  attachment  of  the  muscle,  at  A,  lesser 
trochanter. 

419 


BUTTOCK    OR   HIP    REGION.  421 

by  the  muscles  on  the  anterior  aspect).  The  abduction  causes  an 
apparent  lengthening  of  the  entire  limb,  due  to  the  tilting  of  the 
pelvis. 

These  muscles  are  arranged  in  three  layers  (Fig.  89),  from  without  in- 
ward: (i)  Gluteus  maximus;  (2)  gluteus  medius,  pyriformis,  obturator 
internus,  gemelli,  and  quadratus  femoris;  and  (3)  the  obturator  externus 
and  gluteus  minimus.  Beneath  the  first  layer  (gluteus  maximus)  lies  the 
sciatic  nerve,  which  leaves  the  pelvis  through  the  great  sacrosciatic 
foramen,  below  the  pyriformis.  It  is  most  accessible  to  pressure  at  a 
point  midway  between  the  trochanter  and  tuberosity  of  the  ischium, 
and  this  is  usually  the  painful  spot  in  sciatica,  the  pain  then  being  re- 
ferred along  the  back  of  the  thigh  to  the  knee  (course  of  the  nerve).  The 
nerve  can  be  best  exposed  here  by  dividing  the  fibers  of  the  gluteus 
maximus.  This  nerve  may  divide  either  inside  of  the  pelvis,  just  out- 
side of  the  latter,  or  in  the  middle  third  of  the  thigh,  into  its  two 
principal  branches — the  peroneal  (external  popliteal)  and  tibial  (internal 
popliteal). 

The  sciatic  nerve  is  accompanied  by  an  artery  which  is  a  branch  of  the 
internal  iliac,  and  veins  which  are  branches  of  the  same  named  vein. 
This  sciatic  artery  may  become  an  important  factor  in  the  establishment 
of  collateral  circulation  in  aneurisms  of  the  femoral  or  the  external  iliac 
artery.  In  obstruction  of  the  corresponding  veins  the  free  anastomoses 
of  the  veins  of  this  entire  region  with  the  veins  of  the  pelvis  (branches  of 
the  internal  iliac)  aid  in  the  return  of  the  blood  to  the  vena  cava.  The 
superior  gluteal  artery  and  nerve  emerge  from  the  pelvis  above  the  pyri- 
formis and  the  inferior  gluteal  artery  and  nerve ;  below  it,  the  latter  and 
the  internal  pudic  artery  and  nerve  accompany  the  sciatic  nerve.  The 
internal  pudic  re-enters  the  pelvis  to  be  distributed  to  the  perineum  (see 
Fig.  85).  The  gluteal  vessels  and  nerves  supply  the  muscles  of  this  re- 
gion. The  arteries  are  of  large  size  and  may  be  wounded  in  gunshot  or 
stab  wounds  of  the  hip  and  give  rise  to  severe  hemorrhage.  They  may 
also  be  the  seat  of  aneurisms. 

In  non-impacted  fractures  of  the  neck  of  the  femur  the  above 
muscles  (see  Fig.  136)  pull  the  neck  and  shaft  upward  and  cause  the  leg 
to  roll  outward,  partly  on  account  of  its  weight,  but  mainly  owing  to 
their  function  as  external  rotators.  The  trochanter  thus  comes  to  lie 
above  the  Roser-Nelaton  line  which  was  referred  to  above,  in  the  ex- 
amination of  the  living.  In  either  congenital  or  acquired  backward 
dislocations,  in  fractures  of  the  neck  of  the  femur,  or  in  disease  of  the 
head  and  neck  of  the  bone,  with  destruction  of  the  same,  the  trochanter, 
whose  upper  border  normally  is  in  this  line,  lies  one  to  two  inches 


422  LOWER    EXTREMITY. 

above  it.     Between  the  trochanter  and  the  gluteus  maximus  muscle  lies 
a  large  bursa — the  trochanteric  (see  Fig.  124). 

Inflammation  of  this  bursa  may  cause  swelling,  sensitiveness,  limp- 
ing, and  some  limitation  in  motion,  at  times  greatly  resembling  hip-joint 
disease.  It  lacks,  however,  the  reflex  muscular  spasm  above  spoken  of. 
The  hip- joint  can  be  best  reached,  for  purposes  of  drainage  or  resection, 
through  an  incision  in  this  region  (Langenbeck's)  curving  around  the 
posterior  edge  of  the  greater  trochanter. 

Anterior  Thigh  Region. 

The  upper  portion  of  the  thigh  is  often  described  separately  as  the 
subinguinal  region,  or  groin,  whose  boundaries  correspond  to  those  of 
Scarpa's  triangle.  The  skin  of  this  subinguinal  region  is  very  fine  and 
elastic,  so  that  it  will  permit  of  great  distention  in  cases  of  psoas  abscess, 
femoral  hernia,  etc.  The  superficial  fascia  may  be  divided  into  two 
layers — a  more  superficial  layer,  or  fatty  layer,  and  a  deeper  mem- 
branous one.  The  latter  is  attached  to  Poupart's  ligament  and  to  the 
pubic  arch.  Below  Scarpa's  triangle  it  blends  with  the  superficial  layer. 
These  attachments  of  the  deeper  layer  prevent  fluid,  such  as  extra vasated 
urine,  pus,  etc.,  from  passing  down  the  thigh  from  the  abdomen  or  peri- 
neum. Between  the  superficial  and  deeper  layers  lie  the  inguinal  glands 
(Fig.  120),  the  internal  saphenous  vein  (see  Fig.  130),  and  some  small 
superficial  branches  of  the  femoral  artery  and  vein  (superficial  epigastric, 
circumflex  iliac,  and  external  pudic).  These  latter  vessels  may,  by  their 
anastomoses  with  the  branches  of  the  lumbar,  intercostal,  or  internal 
mammary  arteries  and  veins,  play  an  important  role  (see  Fig.  50)  in 
establishing  a  collateral  circulation.  The  lymphatics  are  arranged  in 
two  sets;  the  upper  lies  along  Poupart's  ligament.  This  upper  set  drains 
the  anal  canal,  perineum,  lower  portion  of  vagina,  male  and  female 
external  genitalia,  and  skin  of  lower  half  of  abdominal  wall  and  gluteal 
region  (see  Fig.  120).  They  frequently  become  enlarged  on  one  or  both 
sides  in  venereal  disease  (soft  chancre,  gonorrhea,  or  syphilis)  or  in  car- 
cinoma of  the  penis,  anus,  vagina,  etc.  Their  suppuration  causes  them 
to  become  firmly  adherent  to  each  other  and  to  the  underlying  femoral 
vessels,  especially  in  lean  people.  The  close  proximity  of  these  large  ves- 
sels must  be  borne  in  mind  in  their  removal. 

The  other  or  lower  set  of  lymph-glands  (crural)  lie  parallel  to  the 
femoral  vessels  over  Scarpa's  triangle.  They  receive  lymph  from  the 
entire  lower  extremity.  When  an  abscess  or  any  enlargement  of  these 
glands  is  found,  the  cause  must  be  looked  for  along  the  entire  limb  to  the 
toes.  They  communicate  with  the  inguinal  glands  and  may  become 


Fig.  129. — Anterior  view  of  the  areas  of  distribution  of  the  sensory  nerves  of  the  skin  (shown  on 
the  left  side  of  the  body),  and  distribution  of  sensation  according  to  segments  of  the  spinal  cord 
(shown  on  the  right  side  of  the  body),  i,  Ophthalmic  nerve.  2,  Superior  maxillary  nerve.  3,  In- 
ferior maxillary  nerve.  The  points  of  exit  of  the  supra-orbital,  infra-orbital,  and  mental  nerves  are 
shown  by  the  markings  X.  4,  Points  of  exit  of  the  anterior  intercostal  branches  of  the  intercostal 
nerves.  5,  Points  of  exit  of  the  lateral  branches  of  the  intercostal  nerves.  6,  Intercosto-humeral 
nerve.  A.M.  and  S.C.,  Area  of  distribution  of  the  great  auricular,  superficial  cervical,  and  supra- 
clavicular  branches  of  the  cervical  plexus.  C,  Circumflex  nerve.  W,  Nerve  of  Wrisberg.  I. C.,  In- 
ternal cutaneous  area.  M.S.,  Musculospiral  area.  M.C.,  Musculocutaneous  area.  U,  Ulnar.  M, 
Median.  R,  Radial.  G.C.,  Genitocrural  area.  The  nerve  is  seen  as  distributing  its  branches  to  the 
genital  region  and  to  the  upper  portion  of  the  thigh.  E.G.,  External  cutaneous  area.  1. 1.,  Ilio-in- 
guinal  area.  I.C.U.,  Internal  cutaneous  area  of  the  thigh.  M.C.U.,  Middle  cutaneous  of  thigh.  I.S., 
Internal  saphenous.  P,  External  popliteal  branches  area.  On  the  right  side  the  division  according 
to  segments  is  seen,  the  letters  C,  D,  L,  and  S  standing  respectively  for  cervical,  dorsal,  lumbar,  ana 
sacral  segments  of  the  cord.  On  the  right  side,  from  the  fourth  dorsal  to  the  twelfth  dorsal  (inclu- 
sive), the  maximum  points,  according  to  Head,  of  the  abdominal  viscera  are  shown  in  relation  to  the 
spinal  segments.  (See  Abdomen.) 

423 


Fig.  130. — Surface  markings  of  principal  veins  on  anterior  surface  of  body,  i,  Ante- 
rior intercostal  veins,  which  arise  from  the  internal  mammary.  2,  Continuation  of  the 
anterior  intercostal  veins,  which  join  with  the  posterior  intercostals,  having  their  origin  in 
the  azygos  veins.  3,  Terminal  branches  of  internal  mammary,  forming  the  superior 
epigastric  veins.  4,  Superficial  inferior  epigastric  vein.  5,  Deep  inferior  epigastric  vein. 
6,  External  iliac  veins.  7,  Femoral  vein.  The  dotted  portion  below  shows  the  popliteal 
vein  as  projected  on  the  anterior  surface  of  the  thigh.  8,  Internal  saphenous  vein,  empty- 
ing into  the  femoral  vein  at  the  saphenous  opening,  o,  Cephalic  vein,  joining  with  10, 
the  basilic  vein,  to  empty  into  the  subclavian.  n,  Median  basilic  vein,  which  is  most 
often  chosen  for  intravenous  transfusion  or  venesection.  12,  Median  cephalic  vein. 
R,  Radial  vein.  M,  Median  vein.  U,  Ulnar  vein. 

425 


ANTERIOR   THIGH   REGION  427 

involved  in  infections  occurring  in  the  area  drained  by  the  latter.  Both 
of  these  sets  of  glands  empty  their  lymph  into  the  deep  iliac  glands  lying 
beneath  the  iliac  fascia.  After  suppuration  and  incision  of  the  super- 
ficial glands,  a  continuation  of  fever  and  septic  symptoms  should  lead  us 
to  suspect  an  extension  to  the  deeper  iliac  glands. 

In  malignant  tumors  of  the  testis  the  involvement  of  the  inguinal  and 
iliac  glands  may  be  greater  than  the  primary  growth. 

The  internal  saphenous  vein  (see  Figs.  130  and  132)  penetrates  the 
fascia  lata  3  to  4  cm.  (i  J  to  ii  inches)  below  Poupart's  ligament,  passing 
across  the  lower  edge  of  the  saphenous  opening  to  empty  into  the  femoral 
vein.  This  vein  is  frequently  ligated  in  this  region  for  the  cure  of  vari- 
cosities  of  its  own  and  tributary  trunks  (see  Fig.  132).  It  can  be  found 
along  the  inner  aspect  of  the  thigh  between  the  superficial  fat  and  the 
fascia  lata  (see  Fig.  131).  It  is  one  of  the  longest  veins  in  the  body,  be- 
ginning on  the  dorsum  of  the  foot  (Fig.  130)  and  returning  the  blood  from 
the  skin  of  the  foot  and  entire  inner  side  of  the  leg  and  thigh.  It  receives 
a  great  many  branches,  and  communicates  freely  with  the  external  sa- 
phenous vein  (see  Fig.  132).  Its  varicosities  may  become  the  seat  of  a 
painful  thrombophlebitis,  or  may  cause  ulceration,  eczema,  etc.,  through 
interference  with  the  cutaneous  blood-supply  (varicose  ulcers).  The 
frequency  of  recurrence  after  ligation  of  the  main  trunk  (Trendelenburg) 
or  of  its  branches  (Schede)  is  due  to  the  many  anastomoses  and  to  the 
fact,  as  shown  in  figure  132,  of  the  occasional  occurrence  of  two  parallel 
trunks  of  equal  size. 

Beneath  the  skin,  fat,  and  superficial  fascia  of  the  groin,  or  sub- 
inguinal  region,  is  the  fascia  lata,  which  is  continuous  with  that  of  the 
hip  and  remainder  of  the  thigh.  Close  to  Poupart's  ligament  it  con- 
sists of  two  layers  (see  Fig.  131);  the  deeper  covers  the  pectineus  muscle 
and  unites  about  ij  inches  below  the  ligament  (Poupart's)  with  the 
more  superficial  (which  is  a  continuation  of  the  iliac  fascia)  to  form 
a  sheath  for  the  femoral  vessels.  To  the  inner  side  of  the  femoral 
vein  an  opening  is  left  through  which  a  femoral  hernia  escapes  (see 
page  234).  The  fascia  lata  has  an  opening  (saphenous)  here,  covered 
by  loose  connective  tissue,  across  the  lower  edge  of  which  the  internal 
saphenous  vein  turns  to  empty  into  the  femoral.  Through  this  opening 
a  femoral  hernia  escapes  toward  the  surface. 

Pus  from  disease  (tuberculosis)  of  the  lower  dorsal  and  lumbar 
vertebrae  follows  the  sheath  of  the  psoas  muscle  to  the  lesser  trochanter, 
and  then  escapes  to  the  surface  through  the  saphenous  opening,  so 
that  a  fluctuating,  painless  swelling  at  this  point  of  the  thigh  should 
always  be  carefully  examined  in  order  to  differentiate  it  from  a 
27 


428  LOWER    EXTREMITY. 

femoral  hernia.  Beneath  the  fascia  lata  lie  the  femoral  artery  and 
vein,  and  the  anterior  crural  nerve.  A  convenient  way  to  remember 
the  relations  is  to  think  of  the  word  "navel" — the  nerve  (anterior 
crural)  lying  to  the  outer  side;  the  artery  next;  the  vein  still  more 
internal;  then  an  empty  space  (see  Fig.  67),  the  crural  or  femoral 
canal;  and,  most  internally,  Gimbernat's  ligament.  The  artery,  in 
addition  to  a  number  of  smaller  superficial  branches  referred  to  above, 
gives  off  the  profunda  femoris  one  inch  below  Poupart's  ligament. 

This  latter  artery,  through  its  anastomoses  with  the  gluteal  and 
sciatic  arteries,  establishes  a  collateral  circulation  after  ligation  of  the 
femoral.  At  times  the  femoral  is  poorly  developed  and  the  main 
blood-supply  of  the  lower  limb  is  derived  through  the  profunda.  The 
femoral  artery  is  quite  accessible  to  pressure  or  ligation  here  in  Scarpa's 
triangle.  The  boundaries  of  the  latter  can  be  readily  palpated  except 
in  stout  persons,  being  the  sartorius  on  the  outer,  the  adductor  longus 
upon  the  inner  side,  and  Poupart's  ligament  above. 

Beneath  the  vessels  here,  lie  the  muscles  in  front  of  the  hip-joint 
and  the  head  and  neck  of  the  femur  and  trochanters.  An  inspection 
of  figure  131  will  aid  in  understanding  these  relations.  The  ves- 
sels lie  directly  upon  the  iliopsoas  and  pectineus  muscles,  which  act 
as  flexors  of  the  hip.  Beneath  the  iliopsoas  lies  a  large  bursa  (the 
iliac),  separating  it  from  the  horizontal  ramus  of  the  pubes.  This 
may  become  inflamed  and  simulate  a  disease  of  the  hip-joint.  In 
about  10  per  cent,  of  all  persons  it  communicates  with  the  joint.  Pus 
from  the  hip-joint  may  escape  through  the  anterior  part  of  the  capsule 
between  the  deep  muscles  here  toward  the  surface.  The  head  of  the 
femur  cannot  be  felt  except  in  very  emaciated  individuals. 

Just  beneath  the  pectineus  muscle  is  the  obturator  opening,  through 
which  the  obturator  nerve  and  vessels  emerge  from  the  pelvis.  Through 
this  gap  in  the  membrane  closing  the  obturator  foramen  a  hernia  (see 
Fig.  69)  may  form  and  be  very  difficult  to  diagnose.  The  close  prox- 
imity of  the  obturator  nerve  here  to  the  head  of  the  bone  explains  the 
frequent  early  reference  of  pain  in  inflammation  of  the  hip-joint  to  the 
knee,  which  the  nerve  also  supplies. 

On  the  inner  side  of  the  thigh  at  this  level  lie  the  adductor  muscles; 
on  the  outer  lies  the  sartorius.  The  rectus  femoris  also  lies  in  front  of 
the  neck  of  the  femur. 

Hip-joint. 

The  relations  and  construction  of  this  joint  can  be  understood  from 
a  horizontal  and  vertical  section  of  the  same  (see  Figs.  78,  131  and  133). 


Fig.  131. — View  of  external  genitalia  of  female,  and  cross-section  of  upper  third  of  thigh, 
i,  Labia  majora.  2  Labia  minora.  3,  Perineum.  4,  Anus.  5,  Internal  saphenous  vein. 
6;  Femoral  vein.  7,  Femoral  artery.  8,  Anterior  crural  nerve.  Upon  the  left  side  of  the 
body  the  black  area  below  7  indicates  the  profunda  femoris.  9,  Adductor  longus  muscle. 
10,  Adductor  magnus.  n,  Sartorius.  12  and  13,  Vastus  externus  and  internus.  14, 
Biceps.  15,  Semimembranosus.  16,  Semitendinosus.  S,  Sciatic  nerve.  P,  Pectineus 
muscle.  R,  Rectus  femoris.  F,  Shaft  of  femur. 


429 


Fig.  132. — Varicosities  of  internal  saphenous  vein.  In  this  case  there  were  two 
internal  sapheni  running  parallel  to  each  other,  indicated  by  the  figures  i  on  both  limbs, 
explaining  a  frequent  cause  of  failure  in  the  Trendelenburg  operation  for  varicose  veins. 


431 


HIP-JOINT.  433 

The  acetabulum  forms  a  hemisphere  which  is  deepened  by  the 
cotyloid  ligament  attached  to  its  edges.  The  head  of  the  femur  exceeds 
a  hemisphere  and  is  not  in  contact  with  the  acetabulum  at  all  points. 
The  center  of  the  acetabulum  is  filled  by  fat,  and  at  this  point  the 
ligamentum  teres,  by  which  the  head  is  held,  is  attached.  It  is  quite 
thin  here,  and  easily  perforated,  especially  in  children,  pus  escaping 
through  the  opening  into  the  pelvis.  With  the  exception  of  this  center, 
the  acetabulum  is  covered  by  cartilage.  The  head  is  also  covered  by 
cartilage  except  at  the  point  of  attachment  of  the  ligamentum  teres 
(see  Fig.  133). 

The  capsule  is  weakest  at  its  posterior  lower  portion,  and  is  most 
easily  perforated  here.  The  capsule  is  attached  in  front  to  the  anterior 
intertrochanteric  line,  above  to  the  inner  aspect  of  the  root  of  the  great 
trochanter,  below  to  the  lower  part  of  the  neck  close  to  the  lesser  tro- 
chanter,  and  behind  to  the  line  of  junction  of  the  outer  and  middle 
thirds  of  the  neck.  Thus,  only  a  part  of  the  posterior  surface  of  the 
neck  is  inclosed  within  the  capsule.  The  synovial  membrane  (see  Fig. 
133)  is  smaller  than  the  capsule,  and  posteriorly,  where  the  attachment 
of  the  latter  is  weak,  the  membrane  may  be  seen  extending  beyond 
the  capsule.  The  upper  epiphyseal  cartilage  of  the  head  of  the  femur 
(see  Fig.  125)  lies  within  the  joint  cavity.  Tuberculosis  of  this  end 
of  the  bone  often  occurs  here,  owing  to  the  bacilli  being  arrested  in 
the  imperfectly  formed  capillaries.  For  this  reason  the  disease  in- 
vades the  joint  at  an  early  stage. 

The  movements  of  the  hip-joint  are  (see  Figs.  122  and  123): 

Abduction — carrying  the  limb  away  from  the  median  line. 
Adduction — carrying  the  limb  toward  the  median  line. 
External  rotation — turning  the  limb  outward. 
Internal  rotation — turning  the  limb  inward. 
Flexion — of  the  thigh  upon  the  abdomen  (Fig.  127). 
Extension — of  the  thigh  upon  the  pelvis,  i.  e.,  pushing  it  back. 

These  movements  are  executed  by  the  muscles  described  in  the  hip 
and  groin,  with  the  aid  of  the  flexors  and  extensors  of  the  knee  (see 
below). 

Dislocation  of  the  hip  may  be  congenital  or  acquired.  In  general 
it  is  less  frequent  than  in  the  shoulder,  owing  to  the  greater  depth 
of  the  acetabulum,  and  the  fact  that  the  capsule  is  strengthened  by 
powerful  ligaments,  especially  in  front  (iliofemoral  and  iliopubic). 
These  latter  ligaments,  as  well  as  the  ligamentum  teres  (Fig.  133), 
which  binds  the  head  to  the  bottom  of  the  acetabulum,  require  an 
enormous  force  to  break  them,  and  thus  greatly  protect  the  joint. 


434 


LOWER    EXTREMITY. 


The  weakest  portion  of  the  capsule  of  the  shoulder  is  below,  while 
that  of  the  hip  is  behind.  Hence  downward  and  forward  dislocations 
(76  per  cent.)  are  more  frequent  in  the  former,  and  backward  and 
upward  in  the  latter  (hip- joint). 

An  acquired  dislocation  (see  Fig.  135)  generally  results  from  an 
exaggeration  of  a  normal  movement  of  the  joint,  i.  e.,  by  indirect  force. 
In  the  backward  variety  an  abnormal  amount  of  flexion  and  abduction 
causes  the  head  to  be  forced  against  the  posterior  weaker  portion  of 
the  capsule,  which  gives  way  after  the  ligamentum  teres  breaks.  In 
the  iliac  form  the  head  rests  upon  the  ilium,  above  and  behind  the 
acetabulum.  In  the  ischiadic  jorm  (rarer)  the  head  rests  upon  the 
ischium.  After  such  a  backward  displacement  the  limb  is  found  to 
be  shorter,  the  trochanter  lies  above  the  Roser-Nelaton  line,  the  limb 
is  adducted,  flexed,  and  rotated  inward. 

As  stated  above,  the  forward  dislocation  is  rarer.  It  is  produced 
by  excessive  outward  rotation  and  abduction,  the  capsule  tearing  in 
its  anterior  portion.  The  head  is  found  either  above  the  pubis  or 
below  it  (see  Fig.  135).  The  limb  is  held  in  a  position  of  flexion, 
abduction,  and  outward  rotation,  the  opposite  of  a  posterior  disloca- 
tion. 

Acquired  dislocation  of  the  hip  may  occur  without  any  appreciable 
trauma,  as  the  result  of  rheumatism,  scarlatina,  or  influenza  (case 
reported  by  author).  Such  displacements  are  usually  posterior  and 
due  to  the  fluid  which  weakens  and  distends  the  capsule,  pushing  or 
pulling  the  head  out  of  the  acetabulum. 

Congenital  dislocation  is  most  frequently  of  the  posterior  variety 
(see  Fig.  134).  It  is  oftener  unilateral,  and  occurs  more  frequently 
in  females  (88  per  cent.).  It  is  due  to  the  head  being  forced  out 
of  the  acetabulum  at  an  early  period  of  intrauterine  life,  the  result 
of  the  closer  application  of  the  uterine  wall  to  the  hip,  owing  to  a  de- 
creased amount  of  liquor  amnii  (Hoffa).  The  acetabulum  becomes 
flatter  (see  Fig.  134),  and  the  capsule  is  usually  stretched  to  inclose  the 
head  in  its  new  resting-place.  The  muscles  around  the  hip  are  shrunken 
and  atrophied. 

Fractures  of  the  Upper  End  of  the  Femur. 

In  the  normal  adult  the  neck  of  the  femur  forms  with  the  shaft  an 
average  angle  of  127  degrees  (see  Fig.  133).  In  elderly  people  this  is 
not  changed,  as  was  thought  formerly.  At  this  latter  age  the  cortex 
of  the  neck  becomes  thinner  and  the  meshes  of  cancellous  tissue  enlarged 
(osteoporosis).  Hence  the  bone  becomes  more  brittle  at  the  neck  and 


Fig.  133. — Vertical  section  of  hip-joint,  seen  from  behind.  The  angle  which  the 
head  under  normal  conditions  forms  with  the  shaft  (127  degrees)  is  marked  out.  I,  Rim 
of  acetabulum  in  vertical  section.  C,  Cavity  of  joint  (exaggerated),  showing  the  extent 
of  the  joint  capsule.  L,  Ligamentum  teres. 


435 


Fig.  134. — X-ray  picture  of  congenital  (right-sided)  dislocation  of  the  femur  at 

the  hip-joint. 


437 


Rotators  of  hip 


Empty  acetabulum 

Relaxed  ilipfemoral 

fascia 


Upper  fragment 


Lower  fragment 
with  adductors  and 
quadriceps  actioti 


Iliopsoas  muscle 


Head  in  front  of  ob- 
turator foramen 


Fig.  135. — Forward  dislocation  of  hip  and  fracture  at  middle  of  shaft  of  femur  show- 
ing action  of  muscles  of  pelvis  and  upper  portion  of  hip  (iliopsoas,  obturators,  etc.),  in 
causing  the  upper  fragment  to  be  pulled  up  and  outward,  and  the  lower  fragment  to  be 
pulled  up  and  inward  by  the  adductor  muscles.  Made  from  #-ray  picture. 


439 


Action  of   ro-   - 
tators  of  hip 
Elevation  of 
trochanter 

above   Roser- 
Nelaton  line 


Eversion  of 
foot 


Iliopsoas 


Inner  frag- 
ment and 
head  of  bone 


Fig.  136. — Fracture  of  neck  of  femur  (from  x-ray  picture)  showing  action  of  rotators 
of  hip  and  iliopsoas  muscle  in  causing  shortening  and  rotation  outward  of  lower  extremity 
(eversion  of  foot,  etc.). 

441 


THE    THIGH. 


443 


is  most  likely  to  break  here  in  elderly  people.  A  slight  fall  upon  the 
trochanter  will  cause  either  an  impacted  or  a  non-impacted  fracture 
(see  Fig.  136).  The  limb  is  shorter,  the  trochanter  lies  above  the 
Roser-Nelaton  line,  and  it  is  rotated  outward.  At  the  same  time  the 
tense  fascia  lata,  extending  from  the  crest  of  the  ilium  to  the  trochanter, 
is  relaxed. 

Such  a  fracture  of  the  neck  of  the  femur  may  occur  as  the  result 
of  violence  in  young  people.  A  separation  of  the  head  from  the  neck 
may  occur  in  children  at  the  upper  epiphyseal  cartilage,  and  also  a 
separation  of  the  trochanteric  epiphysis  (see  Fig.  125),  but  are  rare. 

The  Thigh. 

The  gluteal  (buttock)  and  subinguinal  (groin)  regions  and  the  hip- 
joint  have  been  described  above.  The  skin  is  firmer  and  not  very  elastic. 
There  is  usually  quite  an  amount  of  subcutaneous  fat,  and  in  it  lie  the 
superficial  veins,  the  largest  of  which  is  the  internal  saphenous  (see  Fig. 
132).  This  vein,  after  winding  around  the  internal  condyle,  lies  in  the 
fat  close  to  the  fascia  lata  behind  the  edge  of  the  sartorius  and  accom- 
panied by  the  saphenous  nerve.  Its  course  and  tendency  to  varicosities 
have  been  described  on  page  427.  The  cutaneous  nerves  also  lie  in  this 
fat;  they  are  the  internal,  middle,  and  external  cutaneous.  The  fascia 
lata  forms  a  perfect  sheath  for  all  of  the  muscles  of  the  thigh,  so  that,  if 
torn,  the  muscular  substance  prolapses  through  the  gap.  The  fascia  is 
strongest  on  the  outer  side,  owing  to  the  iliotibial  band  (see  page  418). 
From  the  fascia  lata  two  strong  septa  pass  inward  (see  Fig.  131),  called 
the  external  and  internal  intermuscular  septa  respectively.  These  septa 
form  three  muscular  compartments: 

The  Anterior — containing  the  Quadriceps  and  Sartorius. 

The  Inner — containing  the  Gracilis,  Pectineus  and  the  three  Ad- 
ductors. 

The  Posterior — containing  the  Biceps,  Semitendinosus,  and  Semi- 
membranosus. 

Just  above  the  knee  the  fascia  lata,  after  covering  the  quadriceps  and 
patella,  is  attached  to  the  capsule  of  the  knee-joint.  In  every  fracture  of 
the  patella  there  is  more  or  less  of  a  tear  of  this  fascia  and  of  the  aponeu- 
rosis  of  the  quadriceps,  causing  the  fragments  to  be  pulled  apart.  At  the 
same  time  this  fascial-aponeurotic  expansion  is  so  strong  that,  in  spite  of 
considerable  separation  of  the  fragments  of  the  patella,  with  a  fibrous 
union,  the  patient  still  has  considerable  power  of  extending  the  knee. 
The  relation  of  this  aponeurosis  to  the  patella  will  be  referred  to  later. 

Upon  the  anterior  aspect  lie  the  femoral  artery  and  vein.  From 
28 


444  LOWER    EXTREMITY. 

Poupart's  ligament  to  the  apex  of  Scarpa's  triangle  they  lie  quite  super- 
ficial on  the  inner  side  of  the  sartorius.  In  the  middle  third  of  the  thigh 
they  lie  beneath  this  latter  muscle,  and  in  the  lower  third  in  Hunter's 
canal.  The  artery  thus  lies  on  the  anterior  aspect  of  the  thigh  above, 
the  inner  aspect  in  the  middle,  and  on  the  posterior  aspect  in  the  lower 
portion  of  its  course  (Fig.  128).  The  vein  can  be  easily  separated  from 
the  artery,  it  lies  to  its  inner  side  above,  then  crosses  behind  (posterior) 
it  and  lies  to  its  outer  side  below. 

The  proximity  of  all  these  vessels  to  the  inner  side  of  the  shaft  of  the 
femur  renders  it  easier  to  open  it  for  osteomyelitis,  etc.,  upon  the  outer 
side. 

Upon  the  posterior  aspect  of  the  thigh  the  principal  structure  is  the 
sciatic  nerve  (see  Fig.  131).  It  divides  into  the  peroneal  and  tibial 
nerves  (Fig.  126).  This  takes  place  most  frequently  at  the  upper  end  of 
the  popliteal  space,  but  may  occur  as  high  up  as  its  point  of  exit  from 
the  pelvis,  or  even  inside  of  the  latter.  The  sciatic  gives  off  a  few 
muscular  branches  to  the  biceps,  semimembranosus,  and  semitendino- 
sus.  The  nerve  is  quite  well  surrounded  by  fat  and  connective  tissue 
(see  Fig.  131)  in  its  entire  course.  In  sciatica  its  course  can  be  well 
marked  out  by  the  tenderness  along  the  middle  of  the  back  of  the 
thigh. 

Fractures  of  the  Shaft  of  the  Femur. 

These  occur  usually  at  one  of  three  places: 

1.  Just  below  the  trochanter  (subtrochanteric). 

2.  At  the  middle  of  the  shaft. 

3.  Just  above  the  condyles. 

They  are  generally  oblique;  the  displacement  of  fragments  is  so  great, 
owing  to  the  powerful  muscles  on  all  sides,  that  it  is  necessary  to  apply 
weights  to  the  limb  in  order  to  counteract  them.  In  subtrochanteric 
fractures  the  flexor  muscles  of  the  hip  (pectineus,  ileopsoas)  tend  to  pull 
the  upper  fragment  up  and  forward  on  account  of  their  attachment  to  the 
lesser  trochanter.  In  fractures  of  the  shaft  (see  Fig.  135)  the  glutei  cause 
the  upper  fragment  to  be  abducted  and  the  quadriceps  and  adductors 
pull  the  lower  fragment  up  and  inward.  Unless  this  is  borne  in  mind  in 
the  treatment,  and  the  leg  abducted,  there  will  be  both  shortening,  due 
to  the  overriding  of  fragments,  and  angular  deformity  (Fig.  135)  (bowing 
outward). 

In  supracondyloid  fractures  the  two  heads  of  the  gastrocnemius, 
being  attached  to  the  femur  just  above  the  condyles,  pull  the  lower  frag- 


Crureus  -- 
Vastus  externus  — 


Sciatic  nerve 
Vastus  externus- 


Biceps   - 


Rectus  and  vastus  internus 


Vein 

Femoral  artery 

Int.  saphenous  nerve 

Femoral  vein 

Int.  saphenous  vein 

Gracilis 


Add.  magnus 
Semitendinosus 


Fig-  I37- — Section  through  right  thigh  at  level  of  Hunter's  canal.     Femur  is  seen  just 
above  and  to  outer  side  of  femoral  vessels. 


445 


THE    KNEE    REGION    AND    KNEE-JOINT.  447 

ment  down  and  backward.  Unless  the  proximity  (see  Figs.  128  and 
139)  of  the  popliteal  vessels  and  sciatic  nerve  to  the  bone  is  remembered, 
gangrene  or  paralysis  of  the  leg  may  result  from  pressure  of  the  lower 
fragment  upon  the  structures.  This  can  be  avoided  by  flexing  the  knee 
(use  of  double  inclined  plane  splint)  in  order  to  relax  the  gastrocnemius 
muscle. 

The  femur  is  frequently  divided  below  the  condyles  (subtrochan- 
teric  osteotomy)  to  relieve  deformities  following  injuries  or  diseases 
of  the  hip-joint  or  neck  of  femur.  The  lower  end  of  the  shaft  is  also  at 
times  operated  upon  (Macewen's  osteotomy)  for  relief  of  a  deformity 
known  as  genu  valgum. 

The  Knee  Region  and  Knee-joint. 

The  skin  over  the  front  of  the  knee  is  thin  and  elastic,  so  that  it  per- 
mits of  great  swelling  in  the  knee-joint.  To  both  sides  and  above  the 
patella  there  are  depressions  which  disappear  when  fluid  is  present  in  the 
joint  (Fig.  120).  Normally  the  patella  can  be  moved  readily  up  and 
down,  as  well  as  from  side  to  side.  When  fluid  is  present  in  the  joint,  the 
patella  rides  upon  it,  giving  rise  to  the  phenomenon  of  the  "dancing 
patella,"  or  ballottement.  The  patella  under  these  conditions,  when 
pressed  upon,  rebounds. 

Beneath  the  skin  lies  the  continuation  of  the  fascia  lata  of  the  thigh, 
which  is  so  closely  adherent  to  the  aponeurosis  of  the  quadriceps  and  to 
the  capsule  of  the  joint  as  to  form  one  membrane.  In  fractures  of  the 
patella  this  fascial-aponeurotic  membrane  is  frequently  torn  and  pulls 
the  fragments  apart.  It  covers  the  anterior  surface  of  the  patella,  being 
densely  adherent  to  the  periosteum,  and  is  apt  to  prolapse  into  the  gap 
between  the  fragments  of  a  fracture,  constituting  one  of  the  most  frequent 
causes  of  non-union.  Between  the  skin  and  fascia  covering  the  patella 
lies  the  bursa  ordinarily  spoken  of  as  the  prepatellar  (see  Fig.  139).  In 
reality  it  should  be  called  the  subcutaneous,  to  distinguish  it  from  two 
others.  One  of  the  latter  lies  between  the  fascia  and  aponeurosis  (sub- 
fascial);  the  other  between  the  aponeurosis  and  the  bone  (subaponeu- 
rotic).  These  two  latter  bursae  seldom  inflame.  The  subcutaneous  one 
becomes  either  acutely  inflamed  as  the  result  of  a  fall  upon  the  knee,  and 
may  suppurate,  or  it  becomes  filled  with  mucus  and  rice-bodies  (fibrin) 
as  the  result  of  long-continued  irritation  (housemaid's  knee). 

Upon  the  inner  side  the  knee-joint  is  covered  by  the  sartorius,  semi- 
tendinosus,  and  gracilis,  which  spread  out  before  being  attached  to  the 
tibia.  Upon  the  outer  side  lies  the  biceps. 

Over  the  back  of  the  joint  is  the  popliteal  region,  which  is  bounded 


448  LOWER    EXTREMITY. 

above  and  laterally  by  the  semimembranosus,  semitendinosus,  and  gra- 
cilis  on  the  inner,  and  the  biceps  on  the  outer  side;  below,  it  is  bounded 
by  the  two  heads  of  the  gastrocnemius.  In  the  rhomboidal  space  which 
is  thus  formed  lie  the  popliteal  vessels  and  chief  branches  of  the  sciatic 
nerve  (see  Figs.  128  and  137).  The  skin  is  very  thin,  and  one  can 
palpate  in  most  individuals  the  tibial  nerve  and  popliteal  artery.  Just 
beneath  the  skin  lies  the  external  or  short  saphenous  vein,  which 
penetrates  the  fascia  to  empty  into  the  popliteal.  It  is  shorter  than 
the  internal  saphenous  and  less  apt  to  be  the  seat  of  varicose  veins. 

The  fascia  (popliteal)  is  a  continuation  of  the  fascia  lata.  The  en- 
tire popliteal  space  or  fossa  is  filled  with  fat,  which  protects  the  vessels 
and  nerves  in  it  from  the  direct  effect  of  pressure.  The  popliteal  artery 
is  closely  adherent  to  the  popliteal  vein  throughout  its  course.  The  vein 
lies  more  superficial  and  to  the  outer  side  of  the  artery.  The  artery  lies 
directly  upon  the  femur  and  capsule  of  the  joint  in  the  upper  part  of 
the  back  of  the  knee  and  upon  the  popliteus  muscle  below.  The  close 
relation  of  the  vein  and  artery  to  the  lower  end  of  the  femur  renders  it 
liable  to  injury  in  supracondyloid  fracture  of  the  femur  (see  Fig.  128). 
Their  proximity  to  the  posterior  portion  of  the  capsule  makes  it  neces- 
sary to  use  great  caution  not  to  injure  them  in  resection  of  the  knee. 

The  sciatic  nerve  usually  divides  (see  Fig.  126)  at  the  middle  of  the 
thigh,  or  higher,  into  its  two  principal  branches — the  peroneal  (external 
popliteal)  and  tibial  (internal  popliteal).  The  latter  is  the  more  super- 
ficial (see  Fig.  137)  and  lies  to  the  outer  side  of  the  artery,  crossing  it  and 
the  vein  a  little  lower  down,  to  divide  into  the  anterior  and  posterior 
tibial.  The<peroneal  follows  the  head  of  the  biceps  to  the  head  of  the 
fibula,  winding  around  the  latter  to  the  outer  side  of  the  leg.  It  is  apt  to 
be  wounded  in  this  exposed  position  in  the  faulty  application  of  a  con- 
strictor, or  in  fracture  just  below  the  head  of  the  fibula.  At  the  back  of 
the  knee  is  one  of  the  best  places  to  elicit  pain  on  pressure  in  neuritis  in- 
volving the  sciatic  or  its  main  branches  (Fig.  126). 

Aneurisms  of  the  popliteal  artery  occur  as  the  result  of  long-con- 
tinued pressure  here.  In  the  fat  of  the  popliteal  space  lie  also  a  few 
lymph-glands  (see  Fig.  139)  which  drain  the  back  of  the  leg  and  com- 
municate with  those  of  the  groin. 

The  arterial  and  venous  supply  around  the  knee-joint  is  chiefly  de- 
rived from  the  popliteal  and  tibial  vessels.  They  form  a  superficial  and 
deep  network,  providing  free  anastomosis. 

Beneath  the  semimembranosus  tendon  lies  a  bursa  which  may  inflame 
and  which  at  times  communicates  with  the  joint  (Fig.  124). 

The  keee- joint  is  formed  by  the  patella,  condyles  of  the  femur,  and 


Fig.  138. — Coronal  section  of  knee-joint.  F,  Femur.  The  figure  is  placed  in  the 
diaphysis  of  the  bone;  below  it  is  seen  the  epiphyseal  cartilage  and  the  epiphysis.  The 
relations  of  the  epiphysis  to  the  joint  can  also  be  observed  (see  text).  T,  Tibia.  Placed 
in  the  diaphysis  of  the  bone.  Above  it  is  the  epiphyseal  cartilage  and  upper  epiphysis 
of  the  tibia. 


449 


Popliteal  vein  and 
artery  (the  artery  is  ' 
the    deeper    of   the  j 


Internal  popliteal 
nerve  (tibial) 


Posterior    ligament 
of  knee 


Gastrocnemius 


Anterior  tibial 
artery 


iJ.) :  Probe  in  suprapa- 

tellar  bursa 


"  Prepatellar  bursa 


— •  Ligamentum 

patellae 
Fatty  tissue 
around  joint 

Infrapatellar  recess 
of  joint 


Tibia 


Fig.  139. — Sagittal  section  of  knee-joint  showing  extent  of  synovial  membrane  (Barde- 

leben). 


451 


THE    KNEE    REGION    AND    KNEE-JOINT.  453 

the  tuberosities  of  the  tibia,  the  upper  end  of  the  fibula  not  entering  into 
the  formation  of  the  joint  (see  Fig.  138).  The  joint  can  be  flexed  be- 
yond a  right  angle  (see  Fig.  127)  and  can  be  extended  so  that  the  thigh 
and  leg  are  in  the  same  plane.  There  is  also  a  slight  amount  of  inward 
and  outward  rotation  possible.  In  walking  the  femur  rotates  upon  the 
tibia  in  passing  from  extension  to  flexion,  and  vice  versa,  each  condyle 
gliding  or  rolling  in  a  cup  formed  by  the  semilunar  cartilages,  upon  the 
tibia. 

The  crucial  ligaments  prevent  any  antero-posterior  motion.  Under 
normal  conditions  there  is  scarcely  any  lateral  movement  possible.  In 
injuries  to  the  knee  involving  the  crucial  ligaments  abnormal  forward 
and  backward  movement  of  the  tibia  upon  the  femur  can  be  elicited. 
In  a  tear  of  the  lateral  ligaments  the  joint  acquires  an  abnormal  amount 
of  side-to-side  movement,  and  this  may  give  rise  to  a  genu  valgum  or 
varum  traumaticum.  The  circumference  of  the  knee-joint  can  be  best 
measured  over  the  middle  of  the  patella  (Fig.  127). 

The  capsule  extends  from  2  to  8  cm.  (f  to  3}  inches)  above  the  pa- 
tella —  latterly  it  is  attached  just  above  (J  inch)  the  articular  surfaces  of 
the  condyles;  below,  just  to  the  lower  border  of  the  articular  surfaces  of 
the  tuberosities  (Fig.  139)  ;  and  behind,  on  the  femur  just  above  the  con- 
dyles. In  the  majority  of  people  it  extends  8  cm.  (3}  inches)  above  the 
patella,  so  as  to  include  the  suprapatellar  bursa  (bursa  subcruralis)  (Fig. 


The  epiphyseal  cartilages  of  both  the  femur  and  tibia  are  not  in 
direct  relation  to  the  joint  (see  Fig.  138).  For  this  reason  tuberculous 
foci  can  occur  in  the  bone  without  involving  the  joint,  and  perforate 
externally,  forming  para-articular  abscesses.  The  epiphyseal  line  of 
the  femur  is  higher  (see  Fig.  138)  than  that  of  the  tibia;  hence  one  can 
resect  a  larger  portion  of  the  epiphysis  of  the  femur  without  destroying 
the  cartilage.  In  general,  it  may  be  said  of  every  long  bone  of  the 
body  that  it  ceases  to  grow  when  the  epiphyseal  cartilage  is  destroyed 
by  disease  (tuberculosis,  osteomyelitis),  or  occasionally  by  injury  (epi- 
physeal separation),  or,  thirdly,  through  paralysis  or  injury  of  its  trophic 
nerves  (anterior  poliomyelitis). 

The  capsule  of  the  knee-joint  is  greatly  strengthened  by  extra-artic- 
ular ligaments  on  all  sides  (external  and  internal,  lateral,  anterior  or 
ligamentum  patella,  and  posterior  of  Winslow). 

The  bones  are  held  still  more  perfectly  in  position  by  a  series  of  intra- 
articular  ligaments  —  the  crucial  ligaments,  semilunar  cartilages,  etc. 
These  prevent  the  slipping  of  one  bone  upon  the  other,  excessive  flexion, 
extension,  and  rotary  movements. 


454  LOWER    EXTREMITY. 

The  knee-joint  is  more  accessible  from  the  front  than  from  behind, 
owing  to  the  presence  in  the  popliteal  space  of  large  vessels  and  nerves. 
The  synovial  membrane  is  the  largest  in  the  body,  and  follows  the  cap- 
sule closely.  In  all  forms  of  exudate  into  the  joint  the  swelling  is  at 
once  seen  in  front  (see  Fig.  120),  pushing  the  patella  away  from  its 
resting-place  upon  the  condyles  (mostly  the  external).  The  joint  can 
be  best  drained  by  an  incision  on  either  side  of  the  patella. 

Tuberculosis  begins  somewhat  more  frequently  in  the  tibia  and  femur 
(osseous  form)  than  in  the  synovial  membrane  (synovial  form).  Various 
other  forms  of  acute  and  chronic  synovitis  occur  in  the  knee.  The  great 
tendency  in  all  of  these,  upon  the  part  of  the  patient,  is  to  hold  the  knee 
flexed,  in  which  position  the  inflamed  surfaces  are  furthest  apart.  This 
deformity  may  become  permanent. 

Under  normal  conditions  the  internal  condyle  descends  lower  than 
the  external,  and  in  standing  the  weight  of  the  body  rests  upon  it,  so  that 
an  angle  of  172  degrees  is  formed,  with  closed  side  inward.  The  ex- 
aggeration of  this  occurs  in  genu  valgum,  or  knock-knee,  while  a  dimi- 
nution of  this  angle,  or  its  opening  inward,  is  called  genu  varum,  or  bow- 
leg.  These  deformities  occur  most  often  in  childhood,  when  the  standing 
posture  is  first  assumed.  The  deformity  is  due  to  a  bending  of  the  lower 
end  of  the  femur  in  an  inward  or  outward  direction. 

Fractures  of  the  patella  occur  most  frequently  through  indirect  vio- 
lence. A  sudden  muscular  contraction  of  the  quadriceps  (see  Fig.  140) 
causes  a  fracture  by  practically  pulling  the  bone  apart,  the  lower  end  of 
the  patella  being  firmly  fixed  by  the  ligamentum  patellae.  At  the  same 
time  the  aponeurosis  of  the  muscle  and  the  overlying  fascia  are  torn  ex- 
tensively. 

In  addition  to  tears  of  the  extra-articular  ligaments,  the  semilunar 
cartilages  on  one  or  both  sides  may  be  torn  off,  interfering  with  move- 
ments of  the  joint.  Portions  of  the  articular  cartilages  may  be  separated, 
forming  floating  bodies  which  in  certain  positions  get  between  the  articu- 
lar surfaces  and  cause  locking  of  the  same. 

The  Leg. 

The  upper  boundary  of  the  leg  is  a  line  drawn  immediately  below  the 
tuberosities  of  the  tibia,  the  lower  boundary  is  formed  by  the  malleoli. 
Upon  the  anterior  aspect  is  the  prominent  anterior  border  and  internal 
surface  of  the  tibia,  which  lie  just  beneath  the  skin,  so  that  the  tibia  can 
be  felt  along  its  entire  length  from  the  tuberosities  to  the  malleoli.  Os- 
teomyelitis (acute  suppurative)  occurs  quite  frequently  in  the  tibia  and 
can  be  well  located  on  account  of  the  exposed  position  of  the  bone. 


Fig.  140. — Fracture  of  patella  (made  from  #-ray),  arrow  showing  action  of  quad- 
riceps extensor  in  pulling  upper  fragments  upward,  demonstrating  how  fracture  by  in- 
direct violence  (muscular  action)  can  occur. 


455 


THE    LEG. 


457 


Owing  to  this  superficial  position  the  periosteum  is  frequently  the  seat 
of  a  traumatic  inflammation,  giving  rise  at  times  to  great  tenderness  and 
thickening  of  the  same.  In  syphilis  one  of  the  most  frequent  seats  of  the 
periosteal  inflammation  is  in  the  vertex  of  the  skull,  the  clavicle,  the 
radius,  and  the  internal  surface  of  the  tibia.  In  the  latter  place,  during 
the  acute  stage  of  syphilitic  periostitis,  the  bone  is  greatly  thickened  and 
extremely  sensitive  to  touch.  Even  years  after  such  an  inflammation  has 
passed  away  evidences  of  it  can  be  found  in  a  thickened  condition  of 
this  surface  of  the  tibia. 

The  skin  of  the  anterior  aspect  of  the  leg  has  many  hairs,  especially 
in  the  male.  The  skin  is  more  closely  adherent  to  the  underlying  fascia 
than  in  the  thigh,  so  that  inflammation  of  the  subcutaneous  cellular  tissue 
does  not  spread  as  rapidly,  as  a  rule,  as  in  the  thigh.  On  the  outer  side  lie 
the  peroneal  muscles  (peroneus  longus  and  brevis)  (see  Fig.  141),  and  on 
the  inner  side  of  the  tibia  lie  the  tibialis  anticus  and  the  extensors  of  the 
toes.  The  fascia  is  closely  adherent  to  the  muscles  in  the  upper  third, 
passing  from  the  tibia  to  the  fibula  and  inclosing  all  of  the  muscles  of  the 
anterior  half  of  the  leg  and  the  deeper  blood-vessels  and  nerves  in  two 
compartments  (see  Fig.  141).  The  internal  compartment  contains  the  tibi- 
alis anticus  and  the  extensors  of  the  toes,  the  anterior  tibial  artery,  and 
the  anterior  tibial  (deep  peroneal)  nerve.  The  external  compartment  is 
smaller,  and  contains  the  peroneus  longus  and  brevis  muscles  and  the 
musculocutaneous  (superficial  peroneal)  nerve.  Along  this  surface  be- 
tween the  fascia  and  the  skin  run  many  branches  of  the  saphenous 
(internal  and  external)  veins.  They  frequently  become  thrombosed, 
giving  rise  to  thickenings  and  even  calcareous  masses  along  their 
course.  Owing  to  the  resulting  poor  nutrition  of  the  skin,  varicose 
ulcers  are  especially  prone  to  form  over  the  exposed  anterior  surface  of 
the  tibia  and  around  the  external  or  internal  malleolus. 

The  anterior  tibial  artery  runs  along  the  front  of  the  interosseous 
membrane  to  the  lower  third  of  the  leg,  where  it  becomes  quite  super- 
ficial, lying  upon  the  tibia  (Fig.  128).  It  is  accompanied  by  the  corre- 
sponding deep  veins.  The  latter  may  play  quite  a  role  after  ligation  of 
the  internal  saphenous,  the  theory  being  that  after  ligation  of  the  super- 
ficial veins,  the  deep  veins  should  carry  back  the  blood  of  the  limb;  but 
often  these  are  diseased  or  thrombosed,  so  that  varicose  veins  recur  on 
the  surface. 

The  deep  lymphatics  of  this  region  accompany  the  artery  and  empty 
into  the  popliteal  glands  (Fig.  124).  The  anterior  tibial  artery  is  ac- 
companied by  the  deep  peroneal  or  anterior  tibial  nerve  (Fig.  128). 
This  nerve  supplies  the  tibialis  anticus  and  the  extensors  of  the  toes,  as 


458  LOWER    EXTREMITY. 

well  as  the  peroneus  tertius.  It  is  frequently  involved  in  infantile  spinal 
paralysis  (anterior  poliomyelitis)  as  well  as  the  musculocutaneous  or 
superficial  peroneal  nerve.  The  effects  of  such  paralysis  will  be  referred 
to  on  page  483. 

The  skin  of  the  posterior  aspect  of  the  leg  is  more  elastic  and  there  is 
a  greater  amount  of  subcutaneous  fat.  In  this  layer  lie  both  the  internal 
and  external  saphenous  veins.  The  internal  saphenous  runs  along  the 
inner  edge  of  the  tibia  and  passes  up  to  the  thigh  behind  the  internal  con- 
dyle.  Close  to  the  upper  end  of  the  tibia  is  a  favorite  place  for  large  vari- 
cosities  to  form  in  this  vein  (Fig.  132).  The  vein  is  often  double  in  the 
leg,  the  second  branch  being  a  little  further  back.  This  double  occur- 
rence of  the  internal  saphenous  is  well  shown  in  figure  132.  The  vein  is 
accompanied,  from  the  knee  downward,  by  the  long  or  internal  saphenous 
nerve,  being  intimately  related  to  it.  The  latter  relation  will  explain 
the  frequency  of  pain  along  this  nerve  in  varicose  veins,  especially  when 
inflamed.  The  vein  and  nerve  are  accompanied  by  many  lymphatics, 
which  empty  into  the  inguinal  lymph-nodes  (Fig.  120).  In  lymphangitis 
following  any  infection  of  the  foot  or  leg  their  course  may  be  traced  by  a 
red  line  extending  along  the  inner  border  of  the  leg.  This  internal  sa- 
phenous vein  returns  the  blood  from  the  inner  aspect  of  the  back  of  the 
foot  and  inner  and  front  aspects  of  the  leg.  The  external  or  short  sa- 
phenous also  arises  on  the  back  of  the  foot  (outer  side), but  passes  behind 
the  external  malleolus  along  the  middle  or  posterior  aspect  of  the  leg. 
Close  to  the  knee  it  penetrates  the  fascia,  and,  passing  between  the  two 
heads  of  the  gastrocnemius,  empties  into  the  popliteal  vein  (Fig.  51). 

Close  below,  and  curving  around  the  head  of  the  fibula,  the  musculo- 
cutaneous or  superficial  peroneal  nerve  lies  (Fig.  126).  It  is  exposed  to 
injury  in  the  low  application  of  a  constrictor,  or  after  fractures,  as  ex- 
plained below.  After  such  injury  to  this  nerve,  the  patient  is  unable  to 
raise  the  outer  edge  of  the  foot, — i.  e.,  abduct  it, — on  account  of  the  par- 
alysis of  the  peroneus  longus  and  brevis  muscles;  and  there  is  anesthesia 
of  the  dorsum  of  the  foot  and  outer  aspect  of  the  leg  (see  Fig.  21). 

Back  of  Leg. — The  fascia  of  the  back  of  the  leg  is  a  continuation  of 
that  of  the  anterior  aspect  and  of  the  popliteal  fascia.  It  is  also  adherent 
to  the  tibia  and  fibula  and  forms  a  compartment  for  the  muscles  of  the 
calf.  Through  two  septa  which  it  sends  inward  these  muscles  are 
divided  into  superficial  and  deep  layers.  In  the  superficial  lie  the  gas- 
trocnemius and  soleus,  and  in  the  deep  layer  the  popliteus,  the  long 
flexors,  and  the  tibialis  posticus,  as  well  as  the  posterior  tibial  vessels 
and  nerves.  This  fascia  is  very  thin  above,  but  quite  firm  below  (see 
Figs.  141  and  142).  On  account  of  the  arrangement  of  the  fascia  on  the 


Extensor  longus  - 
digitorum 

! 

Peroneus  longus  — 
Superficial  peroneal  " 
nerve 


Posterior  tibial  nerve  — 
Soleus. 


Outer  head  gastrocnemius  -3 


~  Tibialis  anticus 

-  Anterior  tibial  artery 

-  Tibialis  posticus 

-  Posterior  tibial  artery 

-Popliteus 

•Int.  saphenous  vein 
uner  head  gastrocnemius 


External  saphenous  vein  ji 
Fig.  141. — Cross-section  of  right  leg  below  tuberosities  of  tibia,  looking  upward. 


29 


459 


THE    LEG.  461 

posterior  and  anterior  aspects  of  the  leg,  the  same  conditions  exist  as  in 
the  upper  extremity  (forearm),  where  pus,  after  it  has  once  penetrated 
the  deep  fascia,  causes  an  intermuscular  suppuration  (phlegmon),  which 
may  travel  quite  rapidly  between  the  muscles  on  account  of  the  arrange- 
ment of  the  fascia.  A  large  incision,  and  retracting  the  muscles  so  as  to 
expose  every  portion  of  the  infected  area,  will  correct  this  rapid  spread 
which  the  anatomy  of  the  part  favors. 

The  tendo  Achillis,  formed  by  the  union  of  the  gastrocnemius  and 
soleus,  is  attached  to  the  calcaneus.  It  is  separated  from  it  by  a  small 
bursa  which  may  become  inflamed,  giving  rise  to  a  pain  at  the  insertion 
of  the  tendon  (achillodynia). 

The  posterior  tibial  artery,  accompanied  by  the  nerve  of  the  same 
name,  lies  between  the  superficial  and  deep  layers  of  muscles.  It  lies 
quite  deeply  in  the  upper  portion  of  the  leg  (see  Fig.  141),  but  in  the 
lower  portion  it  becomes  superficial,  winding  around  the  back  of  the  in- 
ternal malleolus  to  reach  the  plantar  surface  of  the  foot  (Fig.  148).  Its 
pulsation  can  be  felt  just  behind  the  posterior  border  of  the  internal 
malleolus.  Both  the  posterior  tibial  artery  and  nerve  are  sufficiently 
removed  from  the  tendo  Achillis  that  there  is  no  danger  of  wounding 
these  vessels  in  a  tenotomy,  especially  if  the  foot  is  forcibly  flexed  (bent 
upward)  to  make  the  tendon  prominent. 

The  peroneal  artery  runs  along  the  outer  aspect  of  this  posterior 
surface;  it  is  the  largest  branch  of  the  posterior  tibial  (see  Fig.  126). 
Both  the  posterior  tibial  and  the  peroneal  arteries  are  accompanied  by 
venae  comites,  which  may  play  a  role,  as  do  those  accompanying  the  ante- 
rior tibial,  in  varicose  conditions. 

The  tibia  is  readily  accessible  for  operations  along  its  entire  internal 
surface.  The  fibula  lies  very  deeply,  except  the  head  of  the  external 
malleolus.  There  is  but  a  slight  amount  of  motion  in  the  upper  joint  be- 
tween the  tibia  and  fibula.  At  their  lower  end  both  of  these  enter  into 
the  formation  of  the  ankle-joint.  The  upper  epiphysis  of  the  tibia  has 
been  referred  to  in  connection  with  the  knee-joint. 

Fractures  of  the  tibia  and  fibula  occur  most  frequently  by  direct 
violence,  such  as  being  run  over,  but  they  may  occur  by  indirect  violence, 
the  foot  or  knee  being  fixed  and  the  bones  breaking  at  their  weakest 
point,  which  is  usually  the  point  of  greatest  curvature;  that  is,  about 
the  middle.  If  the  fracture  is  high  up,  it  may  communicate  with  the 
knee-joint;  or  the  popliteal  vessels  and  musculocutaneous  (superficial 
peroneal)  nerve  may  be  involved,  and  there  is  usually  more  or  less 
tearing  of  the  lateral  ligaments  of  the  joint.  This  is  especially  true  of 
fractures  through  one  or  both  tuberosities  of  the  tibia.  The  most  fre- 


462  LOWER   EXTREMITY. 

qucnt  seat  of  fracture  of  the  tibia  and  fibula  is  about  the  junction  of  the 
middle  and  lower  thirds  of  the  leg.  The  line  of  fracture  is  usually 
oblique,  and,  on  account  of  the  close  proximity  of  the  skin  to  the  internal 
surface  of  the  tibia,  the  fracture  is  often  compound. 

Separations  of  the  upper  or  lower  epiphyses  of  the  tibia  are  rare  (see 
Fig.  125).  There  is  usually  considerable  lateral  displacement  in  the 
fractures  of  the  shaft  of  the  tibia  and  fibula  (see  Fig.  143).  The  swelling 
of  the  leg  may  be  so  great  as  to  hide  the  point  of  fracture.  It  is  necessary 
at  times  to  wait  a  week  or  longer  (without  the  use  of  the  #-ray)  to  deter- 
mine the  extent  of  the  injury.  A  fracture  of  either  bone  of  the  leg  may 
occur  alone.  At  the  lower  end  of  the  tibia  and  fibula  injury  is  often 
accompanied  by  hemorrhage  into  the  ankle-joint,  and  by  tearing  of 
either  the  internal  or  external  lateral  ligaments  of  this  joint.  These 
fractures  close  to  the  ankle  are  usually  produced  indirectly,  by  forcible 
pronation  or  supination  of  the  foot  or  by  sudden  rotation.  This  typical 
fracture  of  the  ankle  is  called  a  Pott's  fracture  (see  Fig.  143),  and  in  it 
various  combinations  can  occur.  The  most  frequent  is  a  tearing-off  of 
the  tip  of,  or  the  entire  internal  malleolus,  with  laceration  of  the  exter- 
nal lateral  ligament;  or  there  may  be  a  fracture  just  above  the  external 
malleolus  alone,  with  tearing  of  the  internal  lateral  ligament  or  lastly 
both  bones  are  broken  above  the  malleoli.  In  the  former  case  there 
has  been  forcible  abduction  of  the  foot;  in  the  latter,  forcible  adduction. 
These  injuries  are  usually  accompanied  by  more  or  less  displacement 
inward  or  outward  of  the  foot,  varying  with  the  extent  of  injury  to 
the  internal  or  external  malleolus  respectively. 

In  the  treatment  of  such  fractures  it  must  not  be  forgotten  that  the 
shaft  of  the  tibia  normally  arches  slightly  forward,  while  that  of  the 
fibula  arches  slightly  backward.  The  great  tendency  in  the  adjustment 
of  such  fractures  is  to  forget  this  fact,  so  that  the  foot  is  pulled  upward 
too  much,  resulting  in  a  backward  curving  of  the  shaft  of  the  tibia, 
instead  of  a  slightly  forward  curve.  At  the  same  time,  unless  the  axis 
of  the  limb  is  kept  strictly  in  view  (see  Fig.  122),  the  result  will  be  an 
inward  or  outward  displacement  of  the  foot  upon  the  leg.  This  axis  of 
the  leg  is  represented  by  a  line  drawn  through  the  middle  of  the 
patella  directly  downward,  midway  between  the  malleoli  (see  Fig. 
122),  and  the  continuation  of  this  line  to  the  space  between  the  great 
and  second  toes.  Care  should  also  be  taken,  in  adjusting  a  fracture  of 
the  leg,  to  keep  the  foot  at  right  angles  to  the  leg,  because  of  a  great  ten- 
dency to  the  pes  equinus  position. 

The  tibia  can  be  best  measured  (see  Fig.  122)  from  the  upper  border 
of  the  internal  tuberosity  to  the  lower  edge  of  the  internal  malleolus. 


Ext.  hall,  longus 
Anterior  tibial  artery 
Anterior  tibial  nerve  •" 


Extensor  comm.  digit.     ^ 


Fibula 
Peroneus longus 


ibialis  anticus 


-Tibia 


O--JV-Post.  tibial  artery 
®---»-Post.  tibial  nerve 


—  Plantaris  tendon 


Flexor longus 
hallucis 


Tendo  Achillis 


Fig.  142.— Cross-section  of  leg  just  above  malleoli. 


463 


Fig.  ! 43. —Fracture  of  both  bones  of  leg  at  middle  third.     (Made  from  *-ray  picture.) 


465 


THE    FOOT.  467 

The  measurement  of  the  entire  lower  extremity  was  mentioned  on  page 
398  by  means  of  a  line  from  the  anterior  superior  spine  of  the  ilium 
through  the  middle  of  the  patella  to  the  lower  border  of  the  inner  mal- 
leolus. 

The  Foot. 

We  speak  of  the  upper  aspect  of  the  foot  as  the  dorsum  and  of  the 
lower  aspect  as  the  plantar  surface.  The  dorsum  is  to  a  great  extent  con- 
vex, the  convexity  being  upward;  the  plantar  surface  is  concave.  In 
stepping  upon  the  foot  only  the  heads  of  the  metatarsal  bones,  especially 
those  of  the  great  and  little  toes,  and  the  heel  touch  the  ground  under 
normal  conditions.  In  many,  however,  there  is  a  slight  amount  of  pres- 
sure upon  the  outer  border  of  the  plantar  surface,  in  addition.  The  re- 
mainder of  the  plantar  surface  is  concave,  the  concavity  looking  down- 
ward, forming  the  arch  of  the  foot.  The  relation  of  this  arch  to  flat-foot 
will  be  referred  to  on  page  471. 

Dorsum. — The  skin  of  the  dorsum  of  the  foot  resembles  that  6f  the 
dorsum  of  the  hand.  It  is  thin  and  elastic,  and  beneath  it  and  the  under- 
lying fascia  there  is  a  loose  connective-tissue  layer  in  \vhich  the  super- 
ficial veins,  lymphatics,  and  nerves  lie.  Hence,  as  in  the  dorsum  of  the 
hand,  edema  is  more  marked  on  this  surface  than  on  the  plantar  sur- 
face, and  infection,  as  in  all  loose  connective-tissue  layers,  spreads 
more  rapidly.  The  superficial  veins  can  be  seen  through  the  skin, 
forming  a  network  called  the  arcus  venosus  dorsalis  (Figs.  132  and 
147).  Along  the  inner  border  of  the  foot  these  veins  empty  into  the 
internal  saphenous;  along  the  outer  border,  into  the  external  or  short 
saphenous. 

The  internal  saphenous  passes  upward  from  the  foot,  lying  in  front 
of  the  internal  malleolus,  and  the  external  saphenous  behind  the  external 
malleolus.  Where  these  veins  begin  are  favorite  places  for  the  formation 
of  varicose  ulcers.  Over  the  dorsum  of  the  foot  one  notices  two  depres- 
sions, one  between  the  internal  malleolus  and  the  prominent  tendon  of 
the  tibialis  anticus,  and  the  other  between  the  external  malleolus  and  the 
tendons  of  the  extensor  longus  digitorum.  These  are  the  most  acces- 
sible portions  of  the  ankle-joint,  and  in  case  of  fluid  in  this  joint 
these  depressions  disappear.  Aspiration  of  the  joint  can  be  best  per- 
formed in  the  depression  to  the  inner  side  of  the  internal  malleolus  (Fig. 

14-). 

The  fascia  covering  the  dorsum  of  the  foot  is  a  continuation  of  that  of 
the  anterior  aspect  of  the  leg.  It  is  continuous  with  that  of  the  plantar 
fascia  along  the  sides  of  the  foot.  It  is  thinner  and  far  more  elastic  than 


468  LOWER    EXTREMITY. 

the  latter,  so  that  pus  is  not  held  under  such  great  tension  as  on  the  plan- 
tar surface. 

Between  the  internal  and  external  malleoli,  on  the  front  of  the  foot, 
there  are  three  important  tendon-sheaths,  the  tendons  of  which  can  be 
distinctly  felt  through  the  skin  here.  These  sheaths  are  that  (see  Fig. 
123)  of  the  tibialis  anticus,  which  begins  above  the  ankle-joint  and  passes 
through  both  portions  of  the  annular  ligament  to  end  below  the  lower; 
that  of  the  extensor  longus  hallucis  (see  Fig.  123),  which  begins  just  above 
the  lower  portion  of  the  annular  ligament  and  passes  through  a  compart- 
ment of  the  latter,  to  end  about  the  level  of  the  scaphoid  bone;  the  third 
tendon-sheath  on  the  front  of  the  foot  is  that  of  the  extensor  longus 
digitorum,  which  begins  about  three-fourths  of  an  inch  above  the  ankle- 
joint  and  extends  about  two  inches  along  the  dorsum  of  the  foot.  Be- 
tween the  external  malleolus  and  the  heel  lie  the  peroneal  tendons,  sur- 
rounded by  a  common  tendon-sheath  (see  Fig.  127),  which  extends  from 
i  to  i  J  inches  above  the  joint  to  the  middle  of  the  outer  border  of  the  foot. 
On  the  inner  side  of  the  dorsum  of  the  foot,  between  the  internal  malleo- 
lus and  the  calcaneus,  lie  the  tendons  of  the  tibialis  posticus  (most  in- 
ternally), the  flexor  longus  digitorum,  the  flexor  longus  hallucis.  Each 
one  of  these  is  surrounded  by  a  separate  tendon-sheath.  It  is  important 
to  remember  the  location  of  these  tendons,  and  especially  of  the  tendon- 
sheaths  (see  Fig.  122).  Inflammation  of  the  latter  is  not  uncommon, 
being  both  acute  and  chronic,  and  unless  their  position  is  remembered, 
the  condition  is  often  diagnosed  as  disease  of  the  ankle-joint  proper.  A 
chronic  inflammation  of  the  tendon-sheaths  of  the  peroneal  and  tibial 
tendons  is  not  uncommon  in  flat-foot,  giving  rise  to  swellings  on  the  inner 
and  outer  sides  of  the  ankle.  Between  the  internal  malleolus  and  the 
calcaneus,  accompanying  the  tendons  here,  lies  the  posterior  tibial  artery, 
which  passes  to  the  plantar  surface  of  the  foot.  Its  pulsation  can  be 
distinctly  felt  here.  The  artery,  which  supplies  the  dorsum  of  the  foot, 
is  a  continuation  of  the  anterior  tibial  artery,  which,  as  was  stated  on  page 
457,  becomes  quite  superficial  at  the  lower  third  of  the  leg  (Figs.  128  and 
142).  It  passes  beneath  the  annular  ligament,  becoming  the  dorsalis 
pedis  artery,  the  main  artery  passing  to  the  inner  side  of  the  head  of  the 
first  metatarsal  bone  and  giving  off  a  transverse  branch  which  runs  to  the 
outer  border  of  the  foot,  and  which,  in  turn,  sends  off  digital  interosseous 
branches  for  each  toe,  similar  to  the  blood-supply  of  the  hand.  The 
lymphatics  of  the  dorsum  of  the  foot  along  its  outer  border  empty  into 
the  popliteal  glands.  Those  along  the  inner  border,  accompanying  the 
saphenous  vein,  empty  into  the  inguinal  nodes  (Fig.  120).  The  nerve- 
supply  of  the  skin  is  derived  from  the  musculocutaneous  (superficial 


Upper  fragment 
of  tibia 


Lower  fragment 
of  tibia 


Astragalus 


Upper  fragment 
of  fibula 


Lower  fragment 
of  fibula 


Fig.  i44.-Fracture  of  lower  ends  of  tibia  and  fibula  (Pott's  Fracture).     (Made  from 

#-ray  picture.) 


469 


THE    FOOT. 


471 


peroneal)  over  the  greater  portion  of  the  dorsum,  the  inner  border  being 
supplied  by  the  internal  saphenous  and  the  external  border  by  the  ex- 
ternal saphenous.  The  termination  of  the  anterior  tibial  nerve  accom- 
panies the  dorsalis  pedis  artery  and  supplies  the  skin  of  the  outer  side  of 
the  great  toe,  as  well  as  the  short  extensors  of  the  toes  (Fig.  21). 

Plantar  Surface. — On  the  plantar  surface  of  the  foot  there  is  a  dis- 
tinct concavity,  referred  to  above.  When  this  concavity  or  arch  is  ab- 
sent, the  deformity  is  known  as  flat-joot.  When  this  is  of  long  standing 
or  congenital,  it  may  give  rise  to  no  symptoms;  but  if  acquired, — as  fre- 
quently happens  in  those  who  are  obliged  to  be  on  their  feet  a  great  deal, 
like  waiters,  etc., — the  condition  becomes  quite  painful,  and  is  often 
mistaken  for  rheumatism.  A  tracing  of  the  sole  of  the  foot  made  upon 
a  blackened  surface  readily  shows  that  the  person  uses  a  greater  area 
to  support  his  weight  than  is  normal. 

The  skin  of  the  sole  of  the  foot  is  much  firmer  and  less  elastic  than 
that  of  the  dorsum.  It  is  very  firm  over  the  points  of  support  (heads  of 
metatarsal  bones,  outer  border  of  foot,  and  heel),  but  thinner  elsewhere. 
Beneath  it,  and  binding  it  to  the  firm  plantar  fasciae,  are  many  strong 
bundles  of  connective  tissue,  the  relation  of  this  connective  tissue  and  of 
the  fat  which  it  holds  in  its  interstices  being  analogous  to  the  condition 
found  on  the  palmar  surface  of  the  hand.  Infection  rapidly  spreads 
from  the  surface  of  the  skin  toward  the  deeper  structures  along  the 
lymphatics  which  accompany  this  connective  tissue. 

The  lymphatic  and  nerve-supply  of  the  skin  of  the  sole  (plantar 
surface)  is  exceedingly  rich.  The  lymphatics,  like  those  of  the  dorsum, 
empty  respectively  into  the  popliteal  (outer  border  of  sole)  and  inguinal 
nodes  (inner  border  of  sole)  (see  Figs.  120  and  124).  The  nerves  are 
derived  from  the  posterior  tibial  nerve.  The  internal  plantar  supplies 
the  inner  portion  of  the  sole  of  the  foot  (see  Fig.  148)  and  corresponds  to 
the  median  nerve  in  the  hand ;  the  external  plantar  supplies  the  outer  por- 
tion of  the  foot  and  corresponds  to  the  ulnar  nerve  of  the  hand.  Be- 
tween the  skin  and  the  fascia  are  several  bursae  which  are  of  more  or  less 
importance.  There  is  one  over  the  outer  aspect  of  the  head  of  the 
metatarsal  bone  which  may  inflame  (bunion),  and  not  infrequently  com- 
municates with  the  metatarso-phalangeal  joint  of  the  great  toe,  especially 
when  the  latter  is  deformed  (hallux  valgus).  There  is  also  a  bursa  over 
the  heel  and  one  over  the  under  surface  of  the  heads  of  the  first  and  fifth 
metatarsal  bones.  Over  the  head  of  the  first  metatarsal  bone  occasion- 
ally an  ulcerative  condition  exists,  clue  to  a  lesion  of  the  trophic  nerves, 
especially  indicative  of  tabes,  known  as  perforating  ulcer  of  the  foot. 

The  plantar  fascia  resembles  the  palmar  fascia  of  the  hand.     It  is 


472  LOWER    EXTREMITY. 

very  tough,  begins  over  the  heel,  and  consists  of  a  central  portion  which 
sends  prolongations  to  the  base  of  each  toe,  and  of  two  lateral  portions, 
which  bind  the  central  portion  to  the  inner  and  outer  borders  of  the  foot. 
It  divides  the  muscles  of  the  sole  of  the  foot  into  three  compartments: 
Those  of  the  big  toe  on  the  inside,  those  of  the  flexors  of  the  other  toes 
and  lumbricales  in  the  middle,  and  those  of  the  little  toe  on  the  outer 
side.  When  suppuration  once  begins  beneath  this  plantar  fascia,  it  re- 
sembles that  in  the  hand,  in  respect  to  the  fact  that  it  is  under  great  ten- 
sion and  causes  severe  pain. 

The  tendon-sheaths  of  the  plantar  surface  of  the  foot  are  not  as  com- 
plex as  those  of  the  palmar  surface  of  the  hand  and  do  not  play  as  great 
a  role  in  the  transmission  of  infection.  Each  flexor  tendon  is  accom- 
panied by  a  tendon-sheath  which  extends  from  the  tip  of  the  toe  to  about 
the  head  of  the  respective  metatarsal  bones,  surrounding  both  the  short 
and  the  long  flexors.  The  tendon- sheaths  referred  to  above,  on  the  inner 
and  outer  aspects  of  the  ankle,  also  extend  to  about  the  middle  of  the  foot 
(peroneal  and  tibial  tendons)  (Fig.  147). 

The  blood-supply  of  the  sole  of  the  foot  is  derived  from  the  continua- 
tion of  the  posterior  tibial  artery.  The  latter  divides,  like  the  posterior 
tibial  nerve,  into  internal  and  external  plantar  branches,  which  begin  just 
after  the  artery  passes  to  the  sole  of  the  foot,  i.  e.,  close  to  the  internal 
malleolus  (Fig.  148).  The  internal  plantar  is  the  smaller  of  the  two.  It 
supplies  the  inner  border  of  the  foot,  uniting  over  the  head  of  the  first 
metatarsal  bone  with  the  plantar  digital  branch  of  the  dorsalis  pedis,  to 
be  distributed  to  the  inner  side  of  the  great  toe.  The  external  plantar 
runs  forward  to  the  inner  side  of  the  base  of  the  little  toe,  and  turns 
abruptly  inward  to  form  the  plantar  arch,  supplying  the  skin  and  giving 
off  branches  which  supply  the  toes  (digital  branches).  It  will  thus  be 
seen  that  the  blood-supply,  both  venous  and  arterial,  is  somewhat  an- 
alogous to  that  of  the  hands  and  fingers,  but  the  veins  must  travel  a  longer 
distance  to  the  center  of  the  venous  system  (heart)  than  in  the  upper 
extremity,  and  this  favors  stagnation  of  blood;  so  that  freezing  of  the 
toes  is  perhaps  a  little  more  frequent  than  that  of  the  fingers. 

Ankle-joints  and  Joints  of  the  Foot. — The  ankle-joint  (talo- 
crural)  is  formed  by  the  astragalus  and  the  adjacent  articular  surfaces  of 
the  tibia  and  fibula  (Fig.  145).  It  permits  of  movements  only  in  two 
directions — sinking  of  the  foot,  or  extension,  and  raising  of  the  foot,  or 
flexion.  The  excursion  from  extreme  flexion  to  extreme  extension  is 
about  70  degrees.  Flexion  can  be  carried  out  over  about  25  degrees 
(see  Fig.  127)  and  extension  over  45  degrees.  Further  extension  or  flex- 
ion is  interfered  with  by  the  strong  ligaments  on  the  anterior  aspect  of 


Fig.  145. — Coronal  section  of  ankle-joint.  T,  Tibia.  The  letter  is  placed  in  the 
epiphysis;  above  it  is  seen  the  epiphyseal  cartilage  and  diaphyses.  F,  Fibula.  This 
letter  is  also  placed  in  the  epiphysis.  A,  Astragalus.  Between  these  three  bones,  tibia, 
fibula,  and  astragalus,  the  cavity  of  the  ankle-joint  is  shown  in  black.  C,  Calcaneus. 
Between  it  and  the  astragalus  above  is  seen  the  talo-calcaneal  articulation. 


473 


Fig.  146. — Horizontal  section  of  foot.  T,  Lower  end  of  inner  malleolus  of  tibia. 
C,  Calcaneus.  A,  Astragalus  (between  A  and  C  observe  the  talo-calcaneal  joint).  CU, 
Cuboid.  S,  Scaphoid,  only  a  portion  of  which  is  seen.  1C,  Internal  cuneiform.  M, 
Metatarsal  bones.  2,  External  cuneiform  bone. 


475 


Superficial  peroneal  nerve 

Tibialis  anticus  tendon 
Extensor  hallucis  longus 

Superficial  peroneal  nerve 

Dorsalis  pedis  artery 

Extensor  hallucis  brevis 


Anterior  tibial  or 
deep  peroneal  nerve 

Internal  saphenous 

vein 
ist  metatarsal  arterv 


External  saphenous  nerve 

(yellow) 

External  saphenous  vein 
(black) 

Peroneus longus  tendon 
Peroneus  brevis  tendon 


Outer  malleolus 
External  saphenous 
nerve 


Extensor  brevis  digi- 
torum 


Fig    j  4  7.— Dissection  of  dorsum  of  foot:  arteries,  dotted;  nerves  shown  in  yellow— veins 

black  (Frohse). 


477 


Posterior  tibial  artery 


Internal  plantar  artery 
Internal  plantar  nerve 

Flexor  longus  digitorum 


Flexor  brevis  digitorum 

External  plantar  artery 
External  plantar  nerve 


Flexor  longus  et  brevis 
tenuous 

Digital  arteries 


Fig.  148. — Dissection  of  plantar  surface  (sole)  of  foot  (Henle):    nerves  black;  arteries 

hatched  outline. 


479 


THE    FOOT.  481 

the  joint,  by  the  posterior  ligaments  and  the  tendo  Achillis  respectively. 
The  outer  malleolus  extends  further  downward  than  the  inner.  A 
reference  to  figures  145  and  146  will  show  the  relation  of  the  three 
bones  which  form  the  ankle-joint  to  each  other. 

The  anterior  ligament  of  the  ankle  is  the  weakest  of  all;  hence  swelling 
in  the  joint  itself  first  appears  here  (see  Fig.  123).  The  posterior,  ex- 
ternal and  internal  lateral  ligaments  are  all  very  powerful;  hence  dis- 
location of  the  ankle-joint  is  either  forward  or  backward,  the  former  be- 
ing somewhat  more  frequent.  In  spite  of  the  strong  character  of  the 
internal  and  external  lateral  ligaments,  they  may  be  torn,  either  in  part 
or  as  a  whole,  the  milder  forms  giving  rise  to  a  sprain,  as  it  is  called,  from 
which  recovery  is  rapid.  When  almost  an  entire  ligament  is  torn,  there 
is  an  abnormal  lateral  movement  at  the  ankle  which  persists  for  a  long 
period. 

The  capsule  of  the  ankle-joint  is  attached  to  the  tibia  and  fibula 
just  above  the  articular  surface  in  front,  but  between  the  two  bones  it 
extends  a  short  distance  upward  (Fig.  145).  The  fact  that  it  is  quite  close 
to  the  skin  on  either  side  of  the  extensor  and  tibialis  anticus  tendons  in 
front  of  the  joint  was  referred  to  above. 

The  epiphyseal  cartilages  (see  Figs.  125  and  145)  lie  close  to  the  cap- 
sule of  the  joint.  In  Pott's  fracture  (see  page  462)  the  articular  surface 
of  the  tibia  and  fibula,  and  at  times  that  of  the  astragalus,  may  be  in- 
volved. Fractures  of  the  astragalus  and  calcaneus — so-called  compres- 
sion fractures — may  occur  without  injury  to  the  tibia  and  fibula,  as  a 
result  of  falling  from  a  great  height  directly  upon  the  sole  of  the  foot. 

The  intertarsal  joints  (see  Fig.  146)  form  a  very  complex  arrange- 
ment with  a  view  to  compactness  and  strength,  the  relation  of  the  tarsal 
bones  being  far  more  intricate  than  that  of  the  carpal  bones.  There  is 
usually  movement  in  all  of  these  joints  simultaneously.  There  is  one 
joint  between  the  astragalus  and  calcaneus  (talo-calcaneo)  which  is 
situated  on  the  inferior  facet  of  the  body  of  the  astragalus,  and  a  corre- 
sponding facet  on  the  anterior  aspect  of  the  os  calcis.  A  second  joint 
is  that  between  the  astragalus,  calcaneus,  and  scaphoid.  This  is  one  of 
the  most  important.  A  third  joint  is  that  between  the  calcaneus  and 
cuboid;  a  fourth  is  between  the  astragalus  and  scaphoid;  a  fifth  between 
the  calcaneus  and  cuboid ;  and  a  sixth  between  the  scaphoid  and  cunei- 
form; a  seventh  between  the  adjacent  contiguous  surfaces  of  the  cunei- 
form bones ;  and  an  eighth  between  the  cuboid  and  cuneiform.  The  only 
places  where  there  are  distinct  synovial  membranes  are  between  the 
astragalus  and  calcaneus,  between  the  astragalus  and  calcaneus  and 
cuboid,  and  between  the  scaphoid  and  cuneiform  bones.  The  move- 


482  LOWER    EXTREMITY. 

ments  in  all  of  these  joints  consist  in  adduction  (that  is,  turning  inward 
of  the  end  of  the  foot)  and  abduction  (turning  outward  of  the  end  of  the 
foot).  Adduction  is  always  accompanied  by  supination  and  abduction 
by  pronation;  that  is,  whenever  the  foot  is  turned  inward,  its  inner  edge 
is  usually  raised  and  the  outer  lowered  (pronation) ;  whenever  the  foot  is 
turned  outward,  the  outer  edge  is  raised  and  the  inner  lowered  (supina- 
tion). These  movements  of  the  foot  are  carried  out  to  a  great  extent  by 
the  peroneal  and  tibial  muscles,  the  former  (peronei)  being  abductors 
and  supinators,  the  latter  (tibial)  being  adductors  and  pronators. 

The  range  of  movement  in  the  intertarsal  joints  is  approximately 
42  degrees.  The  short  joints  of  the  foot  are  the  metatarso-phalangeal 
and  the  interphalangeal.  Dislocations  and  fractures  of  the  metatarsal  and 
phalangeal  bones  are  very  rare,  although  they  may  occur.  Acquired 
deformities  of  the  interphalangeal  joints  occur  in  the  form  of  dislocations 
of  the  phalanges  known  as  hammer-toe. 

Nerve-supply  of  Lower  Extremities  and  Effects  of  Paralysis  of 
Individual  Nerves. 

Paralysis  of  the  branches  of  the  sacral  and  lumbar  plexuses,  which 
supply  the  lower  extremity,  may  occur  as  a  result  of  myelitis,  or  of  any 
condition  which  causes  pressure  upon  the  nerves  of  the  cauda  equina, 
either  before  or  after  leaving  the  spinal  canal  (see  Figs.  149  and  151). 
Paralysis  of  the  individual  nerves,  however,  in  the  lower  extremity,  as  a 
result  of  spinal  paralysis  of  children  (anterior  poliomyelitis),  occurs  more 
frequently  than  in  the  upper  extremity. 

NERVES.  SUPPLY.  RESULTS  OF  PARALYSIS. 

Anterior    Iliopsoas  and  Quadriceps  mus-     i.  Impossible  to  flex  hip,  or  extend  thigh.     2. 
Crural.       cles.  Anesthesia  of  lower  two-thirds  of  thigh,  of 

anterior  region  of  knee,  and  along  inner  side 
of  leg  to  inner  malleolus  (internal  saphenous) 
and  inner  side  of  foot  and  great  toe  (see  Fig. 
103). 

Obtura-     Adductors,   Gracilis,  and  Ob-     i.  Anesthesia  of  skin  area  (see  Fig.  129).     2. 

tor.  turator    externus;  also    skin         Impossible  to  adduct  thigh.     3.  Flexion  of 

of  lower  two-thirds  of  inner         knee  and  inward  rotation  of  tibia  partly  lost 

side  of  thigh  (see  Fig.  129).  (Gracilis).     4.  External     rotation     of     hip 

diminished  (Obturator  externus).  This 
nerve  may  be  paralyzed  as  a  result  of  pres- 
sure of  fetal  head,  or  by  an  obturator  hernia. 

Gluteal  ..Gluteus,  Pyriformis,  Tensor  i.  Impossible  to  rotate  lower  extremity  out- 
fasciae  lata,  Obturator  in-  ward  (paralysis  of  external  rotators).  2. 
ternus,  and  Gemelli.  Impossible  to  extend  hip  (Glutei).  3.  An- 

esthesia of  skin  of  gluteal  region. 


NERVE-SUPPLY    OF   LOWER   EXTREMITY. 


483 


NERVES. 


SUPPLY. 


Peroneal.Tibialis  anticus,  Extensor com- 
munis  digitorum  longus  et 
brevis,  Extensor  hallucis 
longus  et  brevis,  and  the 
three  Peronei  muscles;  also 
supplies  skin  of  outer  and 
posterior  aspect  of  leg  and 
dorsum  of  foot,  except  inner 
and  outer  edges  of  latter. 


Tibial . .  Superficial  and  deep  muscles  of 
calf,  Gastrocnemius,  Soleus, 
Plantar,  Popliteus,  Tibialis 
posticus,  Flexor  digitorum  et 
Hallucis  longus,  and  small 
muscles  on  plantar  surface; 
also  skin  of  plantar  surface 
and  heel. 


RESULTS  OF  PARALYSIS. 

,  Cannot  flex  foot.  2.  The  end  of  the  foot 
droops  in  walking,  due  to  paralysis  of  the 
tibialis  anticus  and  the  Peronei.  3.  Can- 
not extend  the  toes,  due  to  paralysis  of  the 
Extensors.  4.  Impossible  to  adduct  foot 
(pronate)  and  raise  inner  edge.  This  is 
still  possible  to  a  slight  degree  if  the  Tibialis 
posticus,  supplied  by  the  tibial  nerve,  is  pre- 
served. 5.  Impossible  to  abduct  foot  and 
to  raise  outer  edge  of  same.  This  impossi- 
bility to  adduct  or  abduct  foot,  as  the  case 
may  be,  results  in  paralytic  pes  valgus, 
equinus  varus,  and  calcaneus.  6.  Anes- 
thesia of  the  skin  supplied  by  this  nerve  (see 
Fig.  103). 

.  Impossible  to  extend  foot  (Gastrocnemius, 
Soleus,  Plantar,  Popliteus,  and  Tibialis 
posticus).  2.  Impossible  to  flex  toes.  3. 
Lateral  movements  of  foot  lost  on  account 
of  paralysis  of  Interossei,  etc. 


484  THE   SPINE. 


THE  SPINE. 

Examination  of  the  Spine  in  the  Living  Adult.    . 

1.  With  the  patient  standing  with  heels  together,  observe  the  de- 
pression in  the  middle  of  the  back.     It  is  called  "the  spinal  furrow. " 
It  is  somewhat  noticeable  in  the  cervical  region,  and  most  marked 
in  the  lower  dorsal  and  the  upper  lumbar  regions.     It  corresponds  to 
the  space  between  the  trapezii  in  the  cervical  region,  and  to  a  similar 
groove  between  the  larger  erector  spinae  muscles  in  the  dorsal  and 
lumbar  regions. 

2.  Palpate  the  spines  of  as  many  vertebrae  as  possible,  and  mark 
the  same  with  a  blue  pencil.     In  the  cervical  region  only  the  spinous 
processes  of  the  sixth  and  seventh  vertebra?  can  be  distinctly  felt.     The 
latter  (vertebra  prominens)  is  usually  taken  as  the  starting-point  in 
counting  the  dorsal  and  lumbar  vertebrae. 

In  the  dorsal  and  lumbar  regions  the  spines  are  quite  distinct. 
Owing  to  their  obliquity  in  the  dorsal  region,  the  spines  lie  opposite 
the  body  of  the  underlying  vertebra.  For  example,  the  spine  of  the 
sixth  dorsal  corresponds  in  position  to  the  body  of  the  seventh. 

In  the  lumbar  region  the  spines  lie  opposite  the  body  of  the  corre- 
sponding vertebra. 

The  spine  of  the  fifth  lumbar  vertebra  is  very  short,  and  instead 
of  a  prominence  there  is  a  slight  depression. 

This  fifth  lumbar  spine  is  used  in  the  measurement  of  one  of  the 
diameters  of  the  female  pelvis — the  external  conjugate.  The  measure- 
ment is  made  with  the  aid  of  a  pelvimeter  from  the  above  depression  to 
the  upper  border  of  the  symphysis  pubis,  and  is  19  centimeters  (7  j  inches) 
under  normal  conditions  (conjugata  externa,  or  external  conjugate). 

Palpate  the  rudimentary  spines  of  the  first  three  sacral  vertebrae, 
and  also  palpate  the  coccyx. 

3.  Mark  out  the  two  posterior  superior  spinous  processes  of  the 
ilium.     They  are  on  a  line  with  the  third  sacral  spine   (see  Fig.  57). 
They  form  the  guide  to  the  sacro-iliac  joints,  which  lie  below  them. 

4.  Draw  a  line  (with  the  aid  of  a  steel  tape-measure)  joining  the 
highest  points  of  the  two  crests  of  the  ilia.     This  line  passes  through 
the  spine  of  the  fourth  lumbar  vertebra  in  the  median  line.     These 
landmarks  are  frequently  employed  (see  Fig.  57)   to  locate  the  fourth 
lumbar  spine  prior  to  the  operation  of  lumbar  puncture  of  the  dural 
sac  for  diagnostic  or  anesthetic  purposes. 


EXAMINATION   OF    THE    SPINE   IN    THE    LIVING    ADULT.  485 

In  children  the  needle  can  be  inserted  just  beneath  the  fourth 
lumbar  spine,  and  in  adults  J  to  f  of  an  inch  on  either  side.  This 
method  has  been  used  for  diagnostic  purposes  by  withdrawing  some 
of  the  cerebrospinal  fluid  for  examination.  The  same  route  has  been 
used  for  the  injection  of  cocain  and  eucain  solutions  for  spinal  anes- 
thesia. 

5.  Mark  with  a  cross  the  point  of  termination  of  the  spinal  cord 
(see  Fig.  57).     The  cord  ends  at  the  lower  border  of  the  body  of  the 
first  lumbar  vertebra  in  adults.     It  corresponds  fairly  accurately  on  the 
surface  to  the  lower  border  of  the  corresponding  (first  lumbar)  spinous 
process.     In  children  the  termination  of  the  spinal  cord  is  at  the  lower 
border  of  the  body  of  the  third  lumbar  vertebra. 

6.  Mark  the  point  of  termination  of  the  dural  sac  with  a  cross. 
It  is  opposite  the  body  of  the  third  sacral  vertebra,  and  can  be  best 
found   by  drawing  a  line  between  the  two  posterior  superior  spinous 
processes  (see  Fig.  57). 

7.  Observe  the  contour  (seen  from  the  side)  of  the  normal  adult 
spine.     In  the  cervical  region  the  vertebral  column  is  convex  forward 
(lordosis),  so  that  the  bodies  of  the  second  to  the  sixth  vertebrae  can 
be  readily  felt  through  the  mouth.     In  the  dorsal  region  there  is  a 
slight  backward  convexity  (kyphosis),  and  in  the  lumbar  region  a  second 
compensatory  convex  forward  curve  (lordosis).     In  thin  individuals, 
especially  in  women  with  lax  abdominal  walls,  this  normal  lordosis 
is  so  marked  that  the  bodies  of  the  lumbar  vertebrae  can  be  distinctly 
felt  through  the  abdominal  walls.     The  pulsation  of  the  abdominal 
aorta  under  these  conditions  is  so  distinct  as  to  be  associated  in  the 
mind  of  the  beginner  with  the  possibility  of  aneurism  of  that  vessel. 

8.  Observe  the  movements  of  the  spinal  column.     They  are  flexion, 
extension,  and  lateral  movement  or  rotation.     Flexion   and   extension 
can  be  observed  to  be  most  marked  from  the  atlas  to  the  third  dorsal 
vertebra  (cervical),  and  again  from  the  tenth  dorsal  to  the  fifth  lumbar 
vertebra  (lumbar)  (see  Fig.  154).     There  is  but  little  motion  in  the 
dorsal  region  (third  to  tenth  dorsal) .    Pott's  disease  (Fig.  1 53)  causes  early 
fixation  of  the  more  movable  portions  of  the  spinal  column.     This  will 
be  referred  to  again  on  page  491.     Lateral  motion,  in  the  strict  sense, 
can  be  but  slight,  owing  to  the  small  space  given  by  the  compression 
of  the  intervertebral  discs.     Lateral  movements  are  always  accompanied 
by  more  or  less  rotation  of  the  bodies  of  the  vertebrae.     This  movement, 
like  extension  and  flexion,  is  also  most  marked  in  the  cervical  and 
lumbar  regions.     The  rotation  of  the  bodies  may  become  more  or  less 
fixed  under  pathologic  conditions,  resulting  in  the  disease  known  as 


486  THE   SPINE. 

lateral  curvature  or  scoliosis  (see  Fig.  154),  which  will  be  referred  to 
on  page  493. 

In  children  the  spine  is  far  more  flexible  than  in  adults.  There 
is  only  one  curve,  a  backward  one,  and  this  embraces  the  entire  spinal 
column. 

The  Spine  in  a  Clinical  Sense. 

From  a  clinical  standpoint  the  spine  may  be  considered  as  an  elastic 
stick  or  staff  which  is  composed  of  a  number  of  separate  parts,  the 
vertebrae.  The  vertebrae  are  so  firmly  bound  together  through  the 
medium  of  the  intervertebral  discs  and  ligaments  that  they  form  an 
elastic  whole  or  entity,  and  may  be  so  considered  clinically. 

The  vertebrae  articulate  with  each  other  in  two  ways: 

(a)  At  their  bodies  through  the  interposition  of  a  fibrocartilaginous 
disc. 

(b)  The  interneural  articulations.     These  are  the  joints  between 
the  articular  processes  of  adjacent  vertebrae.     There  is  one  joint  on 
each  side  of  the  vertebra.     It  has  a  firm  capsule  and  a  synovial  mem- 
brane. 

The  bodies  are  joined  to  those  above  and  below  them  by  the  firm 
anterior  and  posterior  ligaments,  which  are  attached  along  the  entire 
length  of  the  spine,  thus  giving  it  the  functions  of  a  continuous  struc- 
ture. 

In  addition  to  these  strong  ligaments  binding  the  bodies,  there  are 
powerful  ligaments  connecting  the  laminae,  spines,  transverse  and  artic- 
ular processes. 

The  functions  of  the  spine  are : 

(a)  To  support  the  head  and  trunk. 

(b)  To  afford  a  fixed  point  for  the  movements  of  the  head  and 

of  the  upper  and  lower  extremities. 

(c)  To  form  a  protecting  canal  for  the  spinal  cord  and  its  mem- 

branes permitting  the  spinal  nerves  to  emerge  at  the  various 
levels  through  the  intervertebral  foramina  (see  Fig.  149). 

Normal  Contour  or  Form  of  the  Spine. 

In  adults  the  spinal  column  has  three  curves,  as  follows: 

(a)  A  forward  curve  in  the  cervical  region  (lordosis). 

(b)  Backward  curve  in  the  dorsal  region  (kyphosis). 

(c)  Forward  curve  in  the  lumbar  region  (lordosis). 

It  may  be  well  to  state  at  this  point  that  the  term  kyphosis  is  applied 
to  a  curve  in  the  spine  whose  convexity  is  directed  backward,  that 


Hasilar  artery  on  pons 


Cervical  plexus 

Second  dorsal 
Third  dorsal 

Fourth  dorsal 
Fifth  dorsal 
Sixth  dorsal 

Seventh  dorsal 
Eighth  dorsal 
Ninth  dorsal 

Tenth  dorsal 
Eleventh  dorsal 

Twelfth  dorsal 
First  lumbar 


External  cutaneous 
Anterior  crural 


Sciatic 


Fig.   149. — View  of  brain  and  spinal  cord  in  situ. 


4*7 


NORMAL   CONTOUR   OR    FORM   OF   THE   SPINE. 


489 


M 


the  term  lordosis  is  applied  to  a  curve  whose  convexity  is  directed  for- 
ward,-and  that  a  curve  of  the  spine  toward  either  the  left  or  the  right 
of  the  median  line  of  the  body  is  called  a  scoliosis  or  lateral  curvature. 

These  curves  in  the  normal  adult  spine  arise  in  this  manner:  At 
birth  the  spine  is  perfectly  straight.  When  the  infant  begins  to  sit 
up,  the  weight  of  the  head  and  shoulders  and  the  forward  traction  on 
the  part  of  the  viscera  cause  the  development  of  a  backward  curve  or 
kyphosis,  which  extends  over  the  whole 
spine.  With  the  effort  of  the  child  to  hold 
up  its  head  the  cervical  portion  of  the  spine 
gradually  bends  forward  (lordosis).  The 
third  curve  appears  when  the  child  begins 
to  walk.  In  order  to  maintain  the  upright 
position,  the  child  uses  its  back  and  glu- 
teal  muscles.  At  the  same  time  the  pelvis 
is  inclined  downward,  thus  throwing  the 
center  of  gravity  of  the  body  farther  back. 
In  order  to  compensate  for  this  the  lumbar 
portion  of  the  spine  is  bent  forward,  re- 
sulting in  the  above- re ferred-to  lordosis 
of  that  region.  These  curves  are  not  well 
marked  until  the  seventh  year,  and  can  be 
entirely  obliterated  by  traction  upon  the 
child's  head.  In  adults,  however,  they 
are  practically  permanent.  A  normal  in- 
dividual shows,  when  viewed  from  the 
side,  a  physiologic  or  normal  contour, 
which  is  of  a  wave-like  character  when 
standing  erect,  being  slightly  convex  for- 
ward in  the  cervical,  distinctly  convex 
backward  in  the  dorsal,  and  again  convex 
forward  in  the  lumbar  region.  We  thus 

see  that  the  true  curve  of  the' spine  is  a  kyphosis  or  backward  curve, 
as  exemplified  in  the  dorsal  region  in  the  adult,  and  that  the  cervical 
and  lumbar  forward  curves  (lordosis)  are  compensatory.  When  a  person 
bends  forward,  the  normal  contour  is  a  continuous  convexity  backward, 
the  compensatory  curves  being  apparently  obliterated  (see  Fig.  155). 

A  change  in  the  normal  contour  is  of  as  great  value  in  the  diag- 
nosis of  certain  diseases  of  the  spine  as  the  pain  and  limitation  of  the 
normal  mobility,  which  will  be  referred  to  shortly.  Such  a  change  in 
the  normal  contour  may  arise  gradually  and  not  be  considered  as  a 


Fig.  150. — Diagram  of  motor 
and  sensory  tracts  in  spinal  cord. 
M,  Motor  nerve  and  tract.  S,  Sen- 
sory nerve  and  tract. 


490 


THE   SPINE. 


pathologic  condition.  For  example,  a  person  may  have  a  backward 
curve  (kyphosis)  as  the  result  of  occupation,  especially  those  who  must 
bend  forward  in  their  work.  Again,  one  observes  a  distinct  kyphosis 
in  elderly  persons,  as  the  result  of  the  atrophy  of  the  intervertebral 

cartilages  or  discs,  which  form  nearly 
one-fourth  of  the  entire  length  of  the 
spine. 

Under  pathologic  causes  which 
can  change  the  normal  contour  the 
following  may  be  mentioned : 

(a)  Rachitis  (Rickets). — This  disease 

causes  the  normal  kyphosis  which 
is  present  just  before  the  child 
walks  (see  above)  to  be  exagger- 
ated. 

(b)  Tuberculosis    (Pott's  disease).— 

This  causes  (see  page  494)  an 
early  change  in  the  contour.  In 
some  it  causes  a  sharp  angular 
deformity  with  convexity  back- 
ward, in  others  the  backward 
curve  (gibbus  or  kyphosis)  ex- 
tends over  a  considerable  por- 
tion of  the  spine  (see  Fig.  153). 
It  is  usually  compensated  by 
curves  in  the  opposite  direction 
in  the  nonaffected  regions. 

(c)  Arthritis    deformans   or  osteoar- 

thritis  of  the  spine. — This  causes 
a  backward  curve  involving  the 
entire  spine. 

(d)  Infectious     diseases     (Typhoid, 
Gonorrhea,    Scarlatina,    etc.).— 

Cause  a  backward  curve  which  may  or  may  not  become  per- 
manent. 

(e)  Traumatism. — A  marked  change  in  contour  may  result  suddenly, 
as  after  a  fracture-dislocation  of  the  vertebras,  or  it  can  develop 
gradually  from  a  softening  of  the  bone  after  an  injury.  The 
resulting  change  may  be  either  an  abnormal  forward  or  backward 
curve  (Fig.  151). 

(/)  In  certain  neuroses. — In  hysteria,  in  simple  and  traumatic  neuras- 
thenia, one  frequently  observes  the  development  of  a  backward 
curve,  especially  in  the  dorsal  region,  through  the  weakness  of 
the  back  muscles,  and  a  drooping  forward  of  the  shoulders.  This 
condition  is  usually  a  temporary  one. 


Fig.  151. — Fracture-dislocation, 
showing  crushing  of  the  cord  (Guy's 
Hospital  Museum). 


NORMAL   MOVEMENTS    OF    THE   SPINE.  491 

(h)  In  hip- joint  disease. — This  causes  in  the  early  stages  a  con- 
siderable degree  of  forward  curve  (lordosis)  in  the  lumbar  region 
which  is  compensatory  in  nature.  A  similar  curve  appears  in 
cases  of  congenital  dislocation  of  the  hip. 

Normal  Movements  of  the  Spine. 

As  was  stated  above,  the  vertebrae  articulate  with  each  other  through 
a  median  (intervertebral  discs  uniting  bodies  of  vertebrae)  and  two  lat- 
eral (articular  processes)  articulations.  Although  the  ligaments  which 
serve  to  strengthen  these  joints  and  which  bind  the  arches  to  each 
other  are  very  powerful  and  serve  to  maintain  the  body  in  the  erect 
position,  they  permit  of  a  considerable  degree  of  flexibility  of  the 
spine.  The  muscles  which  serve  to  carry  out  these  movements  are 
those  attached  to  the  front  and  back  of  the  cervical  vertebrae,  those 
which  form  the  great  mass  of  back  muscles  (attached  to  the  dorsal 
and  lumbar  vertebrae),  as  well  as  those  lying  on  the  anterior  surface  of 
the  lumbar  vertebrae  (psoas). 

These  normal  movements  are: 

(a)  Flexion  or  bending  forward  of  the  spine. 

(b)  Extension  or  bending  backward  of  the  spine. 

(c)  Lateral  flexion  or  bending  either  to  the  right  or  left. 

(d)  Rotation  or  revolving  the  spine  upon  its  vertical  axis. 

Flexion  is  most  marked  in  the  cervical  and  lumbar  regions.  The 
dorsal  region  permits  of  but  little  flexion  owing  to  the  thinness  of  the 
intervertebral  discs  and  the  imbrication  of  the  laminae  and  spines  (see 
Fig-  23). 

Extension  is  most  marked  in  the  same  regions  as  flexion. 

Lateral  flexion  is  possible  only  in  a  slight  degree  in  the  lumbar 
region.  In  other  places  it  is  possible  only  through  more  or  less  rotation 
of  the  vertebrae. 

Rotation  is  possible  only  in  the  cervical  and  dorsal  regions. 

All  of  the  movements  of  the  spine  are  best  carried  out  in  the 
cervical  and  dorsal  regions.  The  point  of  greatest  mobility  is  at  the 
junction  of  the  eleventh  and  twelfth  dorsal  and  the  first  lumbar  verte- 
brae. 

The  normal  range  of  movements  of  the  spine  may  vary  greatly  with 
different  individuals.  It  is  limited — i.  e.,  decreased — in  many  of  the 
diseases  which  were  mentioned  above  as  causing  a  change  in  the  normal 
contour.  Any  condition  which  will  cause  an  inflammation  of  the 
osseous  or  ligamentous  structures  of  the  spine  will  cause  an  early  fixa- 


492 


THE   SPINE. 


tion  of  the  same  with  limitation  of  motion.  This  fixation  is  one  of 
the  earliest  symptoms  of  many  diseases.  In  tuberculosis  of  the  spine, 
often  before  there  is  any  deformity,  the  attitude  of  the  patient  will 
aid  in  making  a  diagnosis.  The  child  with  a  disease  of  the  cervical 
region  walks  with  rigid  neck,  often  supporting  its  head  with  the  hands. 
In  dorsal  and  lumbar  tuberculosis  at  an  early  stage  one  can  notice 
the  attempt  at  fixation  by  the  rigidity  of  the  portion  above  and  below 
the  seat  of  disease  through  voluntary  contraction  of  the  muscles  of 


Fig.  152. — Spina  bifida. 


Fig.    153. — Pott's    disease.       Tubercular 
spondylitis  of  middle  dorsal  region. 


the  back.  The  same  limitation  of  motion  can  be  observed  in  all  of 
the  acute  inflammations  of  the  meninges  and  in  neuralgia  involving 
the  spinal  nerve-roots. 

Normal  Lateral  Deviations  of  the  Spine. — In  a  normal  individual 
a  line  joining  the  palpable  tips  of  the  spinous  processes  will  be  found 
to  lie  in  the  median  sagittal  plane  of  the  body.  In  other  words,  there 
is  no  deviation  from  the  median  line.  The  line  joining  the  spines  will 
not  describe  the  various  curves  which  are  formed  by  the  spine  as  accu- 
rately as  one  joining  the  anterior  surfaces  of  the  bodies.  This  is  due 


TUBERCULOSIS   OF    THE   SPINE. 


493 


to  the  fact  that  the  spines  are  not  of  equal  length  or  direction.  Those 
of  the  neck  are  very  short,  those  of  the  dorsal  very  long  and  oblique, 
while  those  of  the  lumbar  region  are  short  and  vertical.  Under  normal 
conditions  there  may  be  a  slight  lateral  deviation  of  the  spines  of  the 
vertebrae  in  the  dorsal  region,  with  compensatory  curves,  just  as  in  a 
scoliosis  above  and  below  the  curvature.  This  normal  deviation  is 
due  perhaps  to  the  greater  development  of  the  muscles  of  one  side  of 
the  body  in  right-handed  individuals. 

Abnormal  Lateral  Deviations  of  the  Spine  (Scoliosis). — These 
are  either  primary  or  secondary.  If  primary,  it  is  not  due  to  a  disease 
of  the  spine,  but  it  is  a  deformity,  most  frequently  the  result  of  a  faulty 
attitude  at  school,  etc.,  in  which  the  vertebrae  attempt  by  a  change 
in  form  to  accommodate  themselves  to  the  attitude.  If  secondary,  it 
occurs  after  any  disease  which  interferes  with  the  equal  use  of  the 
limbs,  such  as  sciatica  or  shortening  of  the  limbs,  or  it  may  occur 
in  wry-neck  (torticollis).  It  can  occur  after  an  empyema  with  extensive 
resection  of  the  ribs,  or  after  poliomyelitis  anterior  as  the  result  of 
the  weakness  or  paralysis  of  the  back  muscles. 

Primary  scoliosis  is  the  more  frequent.  It  is  not  only  a  lateral 
but  also  a  rotary  deformity,  the  vertebrae  being  not  only  compressed 
but  also  rotated  upon  each  other.  When  the  patient  stands  up,  the 
lateral  deviation  is  most  marked  (see  Fig.  154).  When  he  bends  for- 
ward, the  rotary  deformity  is  more  apparent.  At  the  same  time  there 
is  twisting  of  the  contents  of  the  thorax  and  abdomen,  to  which  reference 
was  made  in  the  section  upon  the  thorax.  The  organs  accommo- 
date themselves  to  this  condition  and  it  must  be  borne  in  mind  in 
examining  such  patients.  Owing  to  the  marked  displacements  of  the 
thoracic  and  abdominal  viscera  in  some  cases,  one  has  no  guide  other 
than  to  remember  that  the  greatest  change  in  position  is  on  the  side 
of  the  greatest  convexity. 

Abnormal  Antero-posterior  Deviations  of  the  Spine. — These 
may  occur  either  as  primary  or  secondary.  The  former  are  far  more 
frequent.  The  most  frequent  cause  of  such  primary  deformity  is  Pott's 
disease  or  tuberculosis  of  the  spine. 

Tuberculosis  of  the  Spine. 

This  disease  may  develop  at  any  period,  but  is  most  frequent  between 
the  ages  of  three  and  ten.  It  affects  the  bodies  of  the  vertebrae,  almost 
invariably  causing  a  breaking-down  of  the  bone.  If  this  occurs  rapidly, 
there  is  usually  formation  of  pus.  If  it  occurs  more  slowly,  the  granu- 
lation tissue  is  replaced  by  fibrous  tissue  without  the  formation  of  pus. 
31 


494 


THE   SPINE. 


Owing  to  the  fact  that  the  disease  affects  the  bodies,  these  yield  under 
the  static  pressure  and  sink  in,  giving  rise  to  the  characteristic  back- 
ward deformity.  The  disease  is  most  frequent  at  the  point  of  greatest 
mobility  of  the  spine  (dorso-lumbar  junction)  and  the  deformity  is  most 
frequent  here.  It  may  be  quite  sharp  or  may  involve  the  entire  dorsal 
(Fig.  153)  region.  The  pus  usually  migrates  to  the  surface  of  the 
body.  Its  most  typical  course  is  to  follow  the  sheaths  of  the  trapezius 
or  sternomastoid  in  the  neck.  In  the  dorsal  region  it  follows  the  course 
of  the  psoas  to  the  fold  of  the  groin,  or  it  may  appear  between  the 


Fig.  154. — Scoliosis,  showing  principal  curvature  to  right  in  dorsal  region,  and  com- 
pensatory, in  opposite  direction,  in  lumbar  and  cervical  regions.  The  prominence  of 
the  posterior  portion  of  the  thorax  well  marked  on  side  of  curvature.  The  difference 
in  the  contour  of  the  chest  also  to  be  noted. 


last  rib  and  crest  of  the  ilium,  having  penetrated  the  lumbar  fascia. 
Pus  from  the  lumbar  region  takes  the  same  course  as  that  of  the  dorsal. 
Such  cold  abscesses  are  often  called  gravitation  abscesses.  The  tuber- 
cular inflammation  may  extend  to  the  membranes  of  the  spinal  cord 
and  cause  a  compression  of  the  cord  with  resultant  paralysis.  Such 
a  paralysis  can  also  occur  through  direct  compression  of  the  cord  by 
the  vertebne  themselves,  in  the  same  manner  as  in  a  fracture  (see 
Fig.  151). 

The  symptoms  of  tuberculosis   can  be  readily  understood    if  one 
recalls  the  normal  contour  and  flexibility  of  the  spine  and  the  anatomic 


Fig-  155- — Flexibility  and  normal  contour  of  spine.     Note  the  arch  normally  present  when 
the  spine  is  flexed.     Both  flexibility  and  normal  contour  disappear  in  Pott's  disease. 


495 


THE   SPINAL    CORD    AND    ITS    MEMBRANES.  497 

fact  that  the  spinal  nerves  pass  out  on  either  side  of  the  body  of  the 
vertebra.  Hence  one  would  expect  stiffness,  change  in  contour  (de- 
formity), and  pain  (often  referred  to  the  ends  of  the  corresponding 
nerves)  as  the  principal  symptoms. 

Congenital  Defects  of  the  Spine. 

This  condition  is  called  spina  bifida  and  is  due  to  the  imperfect 
closure  of  the  epiblastic  layer  in  the  embryo  from  which  the  spinal 
cord  and  its  membranes  are  formed.  It  may  involve  the  entire  me- 
dullary canal  or  only  that  portion  corresponding  to  a  single  vertebra. 
If  the  latter,  the  deformity  is  most  frequently  in  the  lumbar  or  sacral 
region  (see  Fig.  152).  It  may  be  only  a  meningocele,  involving 
only  the  membranes,  or  a  myelomeningocele,  embracing  both  cord 
and  membranes. 

Injuries  of  the  Spine. 

These  may  be  very  slight  (sprains  or  twisting)  or  very  severe  (frac- 
ture or  dislocations).  They  may  be  partial,  involving  only  a  portion 
of  the  vertebra,  or  total,  causing  the  complete  destruction  or  dislo- 
cation of  it.  Injury  to  the  vertebrae  may  be  caused  (a)  by  a  direct 
blow,  fracturing  the  arches  (this  is  rare);  (b)  it  may  be  the  result  of  a 
fall  upon  the  head  or  buttocks;  or,  lastly,  (c)  it  follows  forced  flexion 
or  extension  of  the  spine,  resulting  in  either  a  fracture  or  dislocation 
or  both.  In  the  cervical  region  a  dislocation  may  occur  without  frac- 
ture, but  in  the  other  regions  they  are  usually  combined  (Scudder). 
Not  infrequently,  either  as  the  direct  result  of  the  pressure  of  fragments 
or  from  the  pressure  of  a  blood-clot  (hematomyelia)  in  the  spinal  canal, 
paralysis  results  (see  Fig.  151).  A  careful  examination  of  the  extent 
of  motor  and  sensory  paralysis,  as  well  as  the  state  of  the  reflexes, 
will  enable  one  to  judge  fairly  accurately  as  to  the  seat  and  extent 
of  the  lesion.  When  an  injury  is  immediately  followed  by  motor  paral- 
ysis, anesthesia,  and  loss  of  reflexes,  it  is  fair  to  assume  that  the  cord 
has  been  crushed  by  the  fragments.  When  such  symptoms  arise 
gradually,  the  outlook  is  more  favorable  because  the  pressure  is  due  to 
a  blood-clot  (hematomyelia),  which  is  usually  absorbed  with  great 
improvement  in  symptoms. 

The  Spinal  Cord  and  its  Membranes. 

The  spinal  cord  begins  at  the  foramen  magnum  in  the  skull  and 
extends  to  the  lower  border  of  the  first  lumbar  vertebra  (see  Figs.  57  and 
149)  in  adults.  At  its  upper  end  it  passes  into  the  medulla  oblongata, 


498  THE   SPINE. 

and  at  its  lower  end  it  tapers  rapidly  to  a  point — the  conus  medullaris. 
From  the  end  of  the  latter  a  fine  thread  of  tissue  is  continued  down- 
ward to  attach  the  spinal  cord  to  the  back  of  the  coccyx.  In  children 
the  cord  ends  at  the  third  lumbar  vertebra. 

The  spinal  cord  is  amply  protected  from  injury  in  the  following 
manner: 

(a)  The  cord  is  smaller  in  diameter  even  at  its  cervical  and  lumbar 
enlargements  than  the  canal  in  which  it  lies. 

(b)  Its  coverings  separate  it  from  the  bones  of  the  spine  so  as  to 
diminish  the  effects  of  a  jar  or  concussion  of  the  same.     The  dura 
is  not  so  closely  attached  to  the  bones  of  the  spine  as  is  the  dura  of 
the  skull,  because  the  vertebrae  have  an  independent  periosteum  and 
are  not  dependent  upon  the  dura  for  their  nutrition,  as  was  seen  in  the 
case  of  the  bones  of  the  skull.     The  dura  is  separated  from  them  by 
a  soft  mass  of  fat  and  a  considerable  number  of  thin-walled  spinal 
veins.      The  inner  layer  of  the  dura  is  smooth,  as  in  the  skull,  and 
thus  lessens  friction.     In  the  meshes  of  the  pia-arachnoid  there  is,  as 
in  the  brain,  a  large  quantity  of  cerebrospinal  fluid,  which  acts  as  a 
buffer  in  diminishing  the  effects  of  a  jarring  of  the  spine. 

(c)  The  cord  is  not  loosely  suspended  in  the  spinal  canal,  but, 
through  the  aid  of  the   ligamenta   denticulata,  which   pass  from  the 
cord  to  the  inner  surface  of  the  dura  (Fig.  30),  and  the  spinal  nerves, 
it  is  given  great  stability  (see  Fig.  149). 

There  are  31  pairs  of  spinal  nerves,  which  arise  at  different  levels 
of  the  cord.  There  are  8  cervical,  12  dorsal,  5  lumbar,  and  5  coccy- 
geal  nerves  (see  Fig.  149).  These  have  but  little  relation  to  the  cor- 
responding vertebrae,  as  will  be  seen  in  Fig.  149,  owing  to  the  fact 
that  in  the  child  the  bones  grow  more  rapidly  than  the  cord,  and  thus 
the  termination  of  the  cord  in  the  adult  does  not  correspond  to  the  end 
of  the  dural  sac,  which  is  at  the  third  sacral  vertebra  (see  Fig.  57). 
The  cauda  equina,  which  begins  at  the  end  of  the  cord,  is  therefore 
composed  of  lumbar,  sacral,  and  coccygeal  nerves,  which  lie  opposite 
the  lumbar  vertebrae  from  the  second  downward.  Hence  an  injury 
of  the  lumbar  spine  may  not  affect  the  cord  at  all  and  involve  only  the 
nerves  of  the  cauda. 

Segments  of  the  Spinal  Cord. 

Each  pair  of  nerves  is  attached  to  the  cord  by  a  ventral  and  a  dorsal 
root.  The  ventral  is  a  motor  nerve,  and  each  fiber  composing  it  is 
connected  with  a  ganglion  cell  of  the  anterior  horn,  and  may  be  called 
a  motor  neuron  or  entity.  The  dorsal  branch  is  composed  of  sensory 


SEGMENTS   OF    THE   SPINAL    CORD. 


499 


fibers  which  have  their  lowermost  trophic  center  in  the  spinal  ganglia, 
and  is  then  continued  through  the  posterior  horns  of  the  cord  into 
the  posterior  columns.  Each  sensory  fiber  may  be  called  with  its  cor- 
responding cell  a  sensory  neuron  (see  Fig.  149). 

Each  section  of  the  spinal  cord  in  which  a  motor  and  a  sensory 
nerve  arises  is  called  a  segment.  Every  spinal  cord  segment  possesses 
motor,  sensory,  and  reflex  functions,  besides  vasomotor,  visceral,  and 
trophic  activities.  The  entire  trunk  and  extremities  receive  their  in- 
nervation  from  the  corresponding  segments.  This  is  well  shown  in 
figures  70  and  129.  There  is  no  sign  externally  on  the  cord  to  mark 
the  level  of  the  segments.  From  a  study,  however,  of  the  symptoms 
in  any  given  case  one  can  locate  the  lesion  in  a  definite  segment  of 
the  cord. 


LOCALIZATION  OF  FUNCTIONS  IN  SEGMENTS  OF  SPINAL  CORD. 


SEGMENT. 


ad  and  3d  cervical 


5th  cervical  . 


6th  cervical . 


yth  cervical. 


8th  cervical. 


ist  dorsal. 


(Modified  from  Edinger  and  Starr.) 


MUSCLE. 

f  Sternomastoid. 
I   Trapezius. 
-j    Scaleni      and 

muscles. 
f   [  Diaphragm. 


neck 


4th  cervical \ 


Ll 


Lev.     ang.     scapulae 

rhomboideus. 
Supra-     and     infra- 

spinatus. 
Deltoid. 
Supinator  longus. 

Biceps. 

i 

I   Supinator  brevis. 
Serratus  magnus. 
I    Pectoralis          major 

(clavic.  portion). 
[_  Teres  minor. 

f  Pronators. 
Brachialis  anticus. 
Triceps. 

Long     extensors     of 
hand  and  fingers. 

Pect.    major    (costal 

portion). 
Latiss.  dorsi. 
Teres  major. 
Long  flexors  of  fingers 
[_    and  hand. 

f  Extensor  poll,  longus 

et  brevis. 
I   Small      muscles      of 

hand. 


AREA  OF  CUTANEOUS 
SENSATION. 


Neck    and    occipital 
region. 


Shoulder  region. 


Radial  side  of  arm 
to  insertion  of  del- 
toid. 


Radial  side  of  arm 
to  middle  line  of 
middle  finger. 


Ulnar  side  of  hand 
from  middle  line  of 
ring  to  middle  line 
of  middle  or  third 
finger. 

Ulnar  side  of  hand 
to  middle  line  of 
ring-finger. 


Small  area  on  ulnar 
side  of  arm  and 
forearm. 


REFLEXES. 


Dilatation  of  pupil. 


Scapular  reflex. 
Tendon  reflexes  of 
corresp.  muscles. 


Tendon  reflexes  of 
the  corresp.  mus- 
cles. 


Periosteal  reflexes 
of  radius  and  ulna. 

Tendon  reflexes  of 
corresp.  muscles. 


Tendon  reflexes  of 
corr.  muscles. 


Same. 


5oo 


THE   SPINE. 


LOCALIZATION  OF  FUNCTIONS  IN  SEGMENTS  OF  SPINAL  CORD. — (Continued.} 


SEGMENT. 
2d  to  1 2th  dorsal. 


ist   lumbar. 


2d  lumbar. 


3d  lumbai 


4th  lumbar. 


5th  lumbar. 


MUSCLE. 

Muscles  of  back  and 
abdomen. 


AREA  OF  CUTANEOUS 

SENSATION.  REFLEXES. 

Skin  of  thorax  and     Epigastric  and  ab- 
abdomen  and  upper       dominal  reflexes, 
gluteal  region. 


Abdominal  muscles.    ]    Skin  of  pubic  region 
f  Iliopsoas.  and  front  of  scro- 

tum. 

Sartorius.  Anterior    and    inner 

Hamstring     muscles    \     aspects  of  hip. 


(flexors  of  knee). 
Quadriceps   femoris. 


Inward 
thigh. 


rotators    of 


Inner   side   of   thigh 
and  leg  to  malleolus. 

Inner    side    of    foot 

outer  side  of  hip. 
j    Lumbar  region. 


ist  and  2d  sacral 


Adductors  of  thigh- 
Glutei. 

Tibialis  anticus. 
Calf  muscles. 
Flexors  of  knee  (?). 

External   rotators  of 

thigh. 

Flexors  of  foot  (  ?). 
Extensors  of  toes. 
Peronei. 

Flexors  of  toes  and 
foot. 
Small  foot  muscles. 


3d  to  5th  sacral.  Muscles  of  perineum 


Back  of  hip,  of 
thigh,  outer  side  of 
leg  and  foot. 

Dorsum  of  foot. 

Back  of  thigh. 

Outer  side  of  leg  and 
foot. 


Skin  of  anus. 
Skin  of  perineum. 
Skin  over  sacrum. 
Skin  over  genitals. 


Cremaster  reflex. 


Patellar  reflex. 


Gluteal  reflex. 


Plantar   reflex. 
Tendo    Achillis  re- 
flex. 

Bladder    and    rectal 
reflexes. 


The  above  brackets  show  how  the  nuclei  of  the  various  nerves 
extend  over  one  or  more  segments.  In  general,  for  each  nerve  there 
are  one  principal  and  one  or  more  auxiliary  segments. 

On  cross-section  the  spinal  cord  can  be  seen  to  be  divided  into 
anterior,  lateral,  and  posterior  columns.  These  constitute  the  white 
matter  of  the  cord  and  are  composed  of  fibers,  which  transmit  motor 
impulses  jrom  the  brain  (see  Fig.  149),  sensory  impulses  to  the  brain, 
and  other  fibers,  as  will  be  explained.  In  the  central  portion  of  the 
cord  lies  the  gray  matter,  in  the  form  of  the  letter  H,  the  anterior  horns 
being  wider  than  the  posterior.  The  gray  matter  is  composed  of  a 
very  vascular  neuroglia,  of  ganglion  cells,  and  of  non-medullated  nerve- 
fibers.  Every  ganglion  cell  of  the  anterior  horns  serves  as  a  trophic 
center  for  a  corresponding  axis-cylinder  process,  which  passes  to  the 
motor  nerve  or  root.  The  cells  of  the  posterior  horn  probably  have 
a  similar  function  toward  the  sensory  fiber,  especially  those  of  pain 
and  temperature.  The  nerve  entity  which  is  composed  of  the  ganglion 


SEGMENTS    OF    THE   SPINAL    CORD.  501 

cell  and  nerve-fiber  is  called  a  neuron.  As  stated  above,  one  can 
speak  of  a  motor  and  of  a  sensory  neuron.  After  destruction  of  its 
trophic  cell,  the  neuron  degenerates.  After  severing  the  nerve-fiber, 
the  peripheral  portion  degenerates. 

The  first  motor  neuron  is  composed  of  a  cell  of  the  anterior  horn, 
with  the  fiber  leading  to  the  muscle  (see  Fig.  149).  With  this  motor 
fiber,  probably,  the  rami  communicantes  pass  out  of  the  cord  to  the 
sympathetic.  The  second  motor  neuron  is  composed  of  the  fibers  of 
the  pyramidal  tracts,  which  carry  impulses  from  the  brain  downward 
and  have  their  trophic  cells  in  the  cerebral  cortex.  Both  of  these 
motor  neurons  degenerate  peripheral  to  the  seat  of  the  lesion.  When 
the  first  motor  neuron  is  affected,  the  corresponding  muscle  degener- 
ates and  shows  the  reaction  of  degeneration.  When  the  second  motor 
neuron  is  affected,  there  is  paralysis  but  no  loss  of  reflexes,  no  atrophy 
or  change  in  electrical  reaction.  The  anterior  pyramidal  tract  is 
mostly  found  in  the  cervical  portion  of  the  cord.  The  lateral  pyra- 
midal tracts  cross  in  the  pyramids  (see  Fig.  149). 

The  sensory  fibers  have  their  lowermost  trophic  center  in  the  spinal 
ganglia.  Some  of  these  sensory  fibers  communicate  with  the  motor 
cells  in  the  anterior  horn  in  an  indirect  manner,  to  form  a  reflex  arc. 
Others  form  a  communication  with  the  cerebellum,  while  still  others 
connect  those  of  the  two  sides  of  the  cord.  The  remainder  of  the 
fibers  pass  upward  in  the  columns  of  Goll  and  Burdach.  These  seem 
to  carry  the  sensation  of  pressure.  The  sensory  paths  degenerate  in 
an  upward  direction.  Similarly  the  cerebellar  tracts,  which  probably 
have  to  do  with  co-ordination.  The  pain  and  temperature  tracts  seem 
to  come  into  relation  with  the  new  neurons  in  the  posterior  horns  and 
cross  over  to  the  opposite  side  and  pass  upward.  The  Brown-Sequard 
theory,  which  at  first  held  that  all  of  the  sensory  tracts  crossed,  now 
holds  good  only  for  pain  and  temperature.  The  nerves  of  tactile 
sense  seem  to  cross  in  part  only.  The  remainder  of  the  tracts  proba- 
bly connect  one  portion  of  the  spinal  cord  with  the  other. 

As  a  result  of  the  above  knowledge,  we  are  able  in  certain  cases 
to  determine  at  which  level  the  lesion  lies.  In  a  central  lesion  there 
is  no  atrophy  of  the  muscles,  no  disturbance  of  the  reflex  arc,  and 
both  nerves  and  muscles  react  to  electrical  stimulus  in  a  normal  manner. 
The  reflexes  are,  if  anything,  slightly  increased  on  account  of  the  with- 
drawal of  cerebral  inhibition,  resulting  in  a  gradually  developed  spastic 
contracture  (spastic  spinal  paralysis).  When  there  is  an  affection  of 
the  anterior  horn,  the  reflexes  are  lost,  there  is  a  flaccid  paralysis,  a 
fibrillary  contraction  of  the  muscles,  reaction  of  degeneration,  and 


502 


THE   SPINE. 


gradual  loss  of  all  reaction  (poliomyelitis  anterior).  This  may  affect 
a  large  area  or  only  individual  nerves,  as  in  infantile  spinal  paral- 
ysis. A  lesion  of  the  anterior  roots  has  the  same  effects  as  the 
destruction  of  its  ganglion  cells.  A  lesion  of  the  posterior  columns 
through  lack  of  muscular  sensation  leads  to  sensory  ataxia ;  even 
the  sense  of  touch  is  lost.  The  reflex  arcs  are  not  preserved. 
When  the  posterior  roots  are  involved,  all  sensory  stimuli  are  lost, 
as  well  as  the  reflexes  (locomotor  ataxia).  Lack  of  muscular  sense 
here  causes  sensory  ataxia.  Lesions  of  the  posterior  horns,  espe- 
cially close  to  the  central  canal,  cause  disturbances  of  pain  and  tem- 
perature sense  (syringomyelia).  Symptoms  of  irritation  may  occur, 
such  as  tonic  and  clonic  convulsions  in  the  motor  areas,  and  of 
hyperesthesias.  They  seldom  occur  in  affections  within  the  cord,  but 
more  frequently  in  irritations  of  the  root,  especially  of  the  sensory 
horns;  their  appearance  is  of  differential  diagnostic  value. 


INDEX 


ABDOMEN,  195 

blood-supply  of  walls  of,  215,  219 

cavity  of,  in  general,  241 

clinical  relations  of,   195,   196,  208,  219, 

220,    240 

divisions  of,  199 

examination  of,  during  life,  195 

fascia  of,  208 

incisions  of,  223 

lateral  and  posterior  walls  of,  237 

lymphatics  of  walls  of,  215 

muscles  of,  215 

nerves  of  walls  and  contents,  220,  318 

prominence  of,  195 

regions  of,   199 

retraction  of,   195 

skin  of,  208 

stria?  of,  208 
Acetabulum,  443 
Achilles,  tendon  of,  404,  461 
Adenoids,  138 
Air  in  veins,  135 
Alveoli  of  jaws,  80 
Ampulla  of  Fallopian  tube,  309 

of  rectum,   300 

of  Vater,  262 

Anastomosis,  arterial,  in  anterior  abdomi- 
nal thoracic  walls,  163 
of  elbow,  370 
of  hip,  421,  422,  428 
of  knee-joint,  447 

of  deep  veins  of  abdomen,  240 

of  gastro-esophageal  veins,  261 

venous,  at  hip,  421,  422 
at  knee-joint,  447 
in    anterior    abdomino-thoracic    wall, 

163,  219 

Ankle-joint,  472.     See  Joints. 
Antrum,  mastoid,  54 

of  Highmore,  75 
Anus,  artificial,  275 

canal  of,  300 

clinical  relations  of,  163,  301 

imperforate,  301 


Apex-beat,  142 
Appendix,  207 

clinical  relations  of,  207,  224,  238,  239, 

250,  266 

location  of,  266,  275 
Arachnoid,  34 
Arc,  reflex,  501 
Arches,  costal,  196 
crural,  234 

superficial  palmar,  391 
Arm,  carrying  angle  of,  334 

clinical  relations  of,  351,  366 
Artery,  aorta,  146,  196 
arch  of,  187 
axillary,  347 
brachial,  348,  365 

carotid,  common,  100,  101,  116,  127 
external,  100,  101,  123 
internal,   100,   101 
celiac  axis,   199 
cricothyroid,  122 
cystic,   255 

epigastric,  deep,  199,  219 
facial,  70,  10 1,  no 
femoral,  417,  443 
common,  428,  443 
deep,  428 
superficial,  428 
gastric,  260 
gastro-epiploic,  260 
iliac,  common,  199 
external,  199 
innominate,  127 
intercostal,  163 
internal  mammary,  128 

clinical  relations  of,  163 
laryngeal,  122 
inferior,  122 
lingual,  101,  no 
meningeal,  middle,  33,  47 
occipital,  10 1 
of  heart,  182 
of  stomach,  260 
ovarian,  310 


5°3 


5°4 


INDEX. 


Artery,  peroneal,  417,  461 

popliteal,  417 

posterior  circumflex,  348 

pulmonary,  146,  187 

pyloric,  260 

radial,  377 

renal,  199,  283 

subclavian,  101,  127 
branches  of,  128 

temporal,  n 

thyroid,  axis  of,  128 
inferior,  128 
superior,  101,  123 

tibial,  anterior,  417,  457 
posterior,  417,  461,  468 

ulnar,  377 

uterine,  310 

vertebral,  128 

Aryteno-epiglottic  folds,  121,  122 
Ataxia,  locomotor,  502 
Auricles  of  heart,  182 
Axilla,  154,  352 

clinical  relations  of,  352 

relations  in,  352 

skin  of,  352 


BAND,  iliotibial,  398 
Base  line,  Reid's,  47 
Bladder,  base  of,  292 

clinical  relations  of,  292,  305 

female,  305 

fundus  of,  281 

male,  288 

neck  of,  292 

trigone  of,  292 
Body,  ciliary,  98 

perineal,  318 
Bones,  gladiolus,  142 

hyoid,  100,  121 

manubrium,  142 

maxillary,  inferior,  77 
nasal,  90 
of  the  orbit,  95 

of  cranium,  23,  24 

of  face,  75 
Botalli,  duct  of,  187 
Bow  legs,  454 
Brain,  anatomy  of,  41 

clinical  relations  of,  33,  34,  41,  42,  45,  47 

membranes  of,  33 

pulsations  of,  33 
Branchial  cysts,  109 


Breast,  176.     (See  also  Gland,  mammary.) 

pigeon-,  138 
Bronchi,  146,  190 
Bryant's  triangle,  398 
Bunion,  471 
Burdach,  501 
Bursa  of  sole  of  foot,  471 

olecranon,  370 

prepatellar,  447 

subcruralis,  453 

subdeltoid,  357 

suprapatellar,  453 

trochanteric,  422 
Buttocks,  418 

clinical  relations  of,  418 


CALCULI,  277 

pancreatic,  277 

renal,  284 
Canal,  anal,  300,  301 

auditory,  external,  48 

crural,  235 

inguinal,  225 

in  children,  226 

in  female,  234 

in  male,  225 

of  Nuck,  234 
Capsule  of  ankle-joint,  481 

of  elbow-joint,  370 

of  hip-joint,  433 

of  kidney,  278 

of  knee-joint,  453 

of  shoulder-joint,  357 

suprarenal,  283 
Caput  Medusae,  220 
Carotid  sheath,  115,  116 

triangle,   115 
Cartilage,  alar,  90 

arytenoid,  121 

costal,  196 

cricoid,  100,  122 

epiglottis,  121 

epiphyseal,  of  femur,  453 
of  tibia,  453 

intervertebral,  486,  490 

laryngeal,  121 

quadrangular,  of  nose,  93 

semilunar,  453 

thyroid,  too,  121 
Caudate  nucleus,  41 
Cavity,  abdominal,  241 

peritoneal,  242,  246,  249* 


INDEX. 


5°5 


Cavity,  pleural,  189 

tympanic,  53 
Cecum,  266,  271 
Centers,  cerebral,  42 
Cerebellum,  42 
Cerebrospinal  fluid,  34 
Cerebrum,  41 
Chamber,  anterior,  of  eye,  97 

aqueous,  of  eye,  97 

posterior,  of  eye,  97 
Chin,  double,  102 
Choroid,  97 
Ciliary  body,  98 
Circle,  vicious,  260 
Claw-hand,  392 
Cleft  palate,  69,  85,  86 
Colics'  fracture,  391 
Colon,  ascending,  271 

blood-supply  of,  272,  275 

descending,  271 

iliac,  272,  275 

pelvic,  272,  275 

transverse,  271 
Colostomy,  225 
Columns  of  Morgagni,  301 

of  spinal  cord,  501 
Congenital  fistula,  109 
Conjoined  tendon,  216 
Conjunctiva,  98 
Contraction,  Dupuytren's,  383 
Conus  medullaris,  499 
Coracoid  process,  142 
Cord,  spermatic,  298 

spinal,  497.     (See  also  Spinal  cord.} 
Cornea,  97 
Corpus  callosum,  41 

spongiosum,  295 
Costal  arches,  196 

cartilage,  196 
Cranial  nerves,  45,  47 
Cranium,  anatomy  of,  general,  23 

clinical  relations  of,  24,  27,  28 

contents  of,  28 

examination  of,  during  life,  in  adult,  1 1 

examination  of,  during  life,  in  infant,  12 

malformations  of,  acquired,  28 
congenital,  28 

topography  of,  general,  12 
Cricoid  cartilages,  100,  122 
Crural  arch,  234 

canal,  235 

ring,  235 

septum,  235 


Cryptorchismus,  299 
Cul-de-sac  of  Douglas,  306 
Cut  throat,  135 
Cystotomy,  suprapubic,  242 
Cysts,  branchial,  109 


DARTOS  of  scrotum,  215 
Diaphragm,  178 

nerve  supply  of,  188 
Discs,  intervertebral,  490 
Diverticulum,  Meckel's,  246 
Double  chin,  102 
Douglas,  cul-de-sac  of,  306 
Drop-wrist,  392 
Duct,  Botalli,  187 

common  bile,  255,  262 

cystic,   255 

ejaculatory,  295 

hepatic,  255 

nasal,  98 

of  seminal  vesicle,  295 

pancreatic,  262 

Steno's,  77 

thoracic,  128,  188 

Wharton's,  no 
Duodenum,  261 

clinical  relations  of,  256 
Dupuytren's  contraction,  383 
Dura  mater,  33 


EAR,  48 

clinical  relations  of,  48,  53,  54,  59 

external,  48 

internal,  59 

middle,  53 
Elbow-joint,  ankylosis  of,  371 

clinical  relations  of,  370,  371 
Emphysema  of  forehead,  95 

of  lungs,  138 

of  thoracic  walls,  175 
Ensiform  process,  196 
Enterocele,  233 
Epididymis,  298 

Epiphyses    of    femur,    trochanteric,   sepa- 
ration of,  443 
upper,  separation  of,  443 

of  humerus,  lower,  separation  of,  372 
upper,  separation  of,  362 

of  tibia,  separation  of,  462 
Epiplocele,  233 
Esophagotomy,  127 


506 


INDEX. 


Esophagus,  124,  182 

clinical  relations  of,  127,  187,  261 

passing  stomach-tube,  127 

portions  of,  187 
Eustachian  tube,  59 
Extremity,  lower,  398 

upper,  322 
Eye,  clinical  relations  of,  97,  98 

anterior  chamber  of,  97 

aqueous  chamber  of,  97 

posterior  chamber  of,  97 

muscles  of,  96 
Eyelids,  98 

FACE,  60 

blood-supply  of,  70 

bones  of,  75 

clinical  relations  of,  60,  67-70,  75-79 

examination  of,  during  life,  60 

nerve  supply  of,  70 

regions  of,  67 
Facial  artery,  70,  101,  110 

nerve,  76 

vein,  70 
Fallopian  tubes,  309 

clinical  relations  of,  309 
Fascia,  axillary,  352 

bicipital,  369 

cervical,  deep,  109,  128,  136 

clinical  relations  of,  383 

cribriform,  235 

endothoracic,  154 

iliac,  238 

infundibuliform,  225 

lata,  427 

lumbar,  238 

palmar,  383 

pectineal,  234 

pectoral,  deep,  154,  351 

pelvic,  287 

perinephric,  278 

plantar,  471 

popliteal,  448 

prevertebral,  135 

fenal,  278 

spermatic,  external,  215 

transversalis,  216   237 
Felon,  383 

Femur,  clinical  relations  of,  421,  434,  444 
Fibers,  intercolumnar,  215 
Finger,  clinical  relations  of,  383 

lymphatics  of,  383 
Fissure  of  Rolando,  47 


Fissure  of  Sylvius,  47 

Fistula,  congenital,  109 

Flat-foot,  471 

Flexure,  duodeno-jejunal,  200,  265 

hepatic,  271 

sigmoid,  207,  272 

splenic,  271 

Fluid,  cerebrospinal,  34 
Folds,  aryteno-epiglottic,  121,  122 
Follicles,  solitary,  of  intestine,  275 

of  tonsil,  86 
Fontanelles,  24 
Foot,  398,  467 

blood-supply  of,  468,  472 

clinical  relations  of,  467,  471,  482 

dorsum  of,  467 

flat-,  471 

lymphatics  of,  471 

nerve  supply  of,  471 

plantar  surface  of,  471 
Foramen  of  Magendie,  34 

of  Winslow,  246,  249 

ovale,  182 
Forearm,  377 

clinical  relations  of,  377,  391 
Fossa,  duodeno-jejunalis,  265 

iliac,  237 

infraclavicular,   145,  322 

ischiorectal,  301 

Mohrenheim's,  154,  322 

of  cranium,  24,  45,  46 

popliteal,  448 

recto-uterine,  245 

recto vesical,  245 

subcecalis,  271 
Frenum  of  tongue,  87 

clinical  relations  of,  87 

GALL-BLADDER,  255 

clinical  relations  of,  224,  255,  256,  262 
Gall-stones,  255 
Ganglion,  Gasserian,  63,  78,  79 

Meckel's,  78 

superior  cervical,  116 
Gasserian  ganglion,  63,  78,  79 
Genitalia,  external  female,  317 
Genu  valgum,  454 

varum,  454 
Gland,  bronchial,  190 

cervical,  deep,  116 

crural,  422 

cubital,  377 

iliac,  239 


INDEX. 


507 


Gland,  inguinal,  239,  422 

lachrymal,  98 

lymph,  no 

mammary,  176 

blood-supply  of,  176 
clinical  relations  of,  154,  176 
lymph  supply  of,  176 
nerve  supply  of,  176 

prostate,  297 

salivary,  no 

submaxillary,  no 

submental,  no 

thyroid,  124 

blood-supply  of,  124 
Globus  major,  298 

minor,  298 
Glottis,  chink  of,  121 

rima  of,  121 
Goll,  501 
Grooves,  bicipital,  333 

Mohrenheim's,  322 
Gubernaculum  testis,  299 
Guides,     surgical.     (See     Markings,     sur- 
face.} 
Gums,  clinical  relations  of,  79,  80,  85 


HALLUX  valgus,  471 
Halsted's  operation,  181 
Hammer-toe,  482 
Hand,  378 

clinical  relations  of,  378 
Hare-lip,  69,  85 
Haustra,  275 

Hearing,  center  of,  in  brain,  42 
Heart,  182 

clinical  relations  of,  141,  175,  182 
Heister's  valve,  255 
Hemispheres  of  brain,  41 
Hemorrhoids,  301 
Hernia,  cecal,  271 

diagnosis,  differential,  between  inguinal 

and  femoral,  236 
enterocele,  233 
epiplocele,  233 
femoral,  course  of,  235 
coverings  of,  235 
reduction  of,  236 
inguinal,  complete,  233 
contents  of,  233 
coverings  of,  233 
direct,  226 
in  female,  234 


Hernia,  inguinal,  in  male,  226 
indirect,  226 
interstitial,  233 
into  the  fossa  subcaecalis,  271 
nerves  in  relation  to,  234 
oblique,  226 
scrotal,  233 
straight,  233 
strangulation  of,  233 
obturator,  428 
paraumbilical,  237 
postoperative  ventral,  224 
retroperitoneal,  265 
scrotal,  233 
strangulation  of,  233 
umbilical,  236 
in  adults,  237 
in  children,  236 
strangulation  of,  237 
Hesselbach's  triangle,  233 
Highmore,  antrum  of,  75 
Hilum  of  left  kidney,  283 
Hip-joint,    clinical   relations  of,   418,   423 

433 

movements  of,  433 
Houston's  valve,  300 
Humerus,  clinical  relations  of,  361,  366 

dislocation  of,  358 

fracture  of,  361 

upper  epiphysis  of,  358 
Humor,  aqueous,  97 

vitreous,  97 
Hydrocele,  298 
Hydrocephalus,  34 
Hyoid  bone,  100,  121 


ILIUM,  265 

blood-supply  of,  260 

spines  of,  196 
Incisions  for  appendix,  224 

for  gall-bladder,  224 

for  kidney,  240 

for  laparotomy,  223 

for  stomach,  225 

in  fingers  for  suppuration,  391 

Langenbeck's,  422 
Inguinal  canal,  225 

region,  225 

ring,  225 

Intercolumnar  fibers,  215 
Internal  ear,  59 
Intestine,  large,  266 


5o8 


INDEX. 


Intestine,  large,  clinical  relations  of,  271 

divisions  of,  271 
small,  261 

clinical  relations  of,  266,  275 

peristaltic  wave  of,  215 
Introitus  vaginae,  317 
Intubation,  122 
Iris,  97 
Isthmus  of  Fallopian  tube,  310 


JAW,  lower,  77 
Jejunum,  265 

blood-supply  of,  266 
Joint,  acromioclavicular,  351 
ankle-,  472 

clinical  relations  of,  467,  481 
elbow-,  370 

ankylosis  of,  371 
clinical  relations  of,  370,  371 
foot,  472 
hip-,  428 

clinical  relations  of,  418,  423,  433 
movements  of,  433 
intertarsal,  481 
knee-,  447,  448 

clinical  relations  of,  453 
sacro-iliac,  287 
shoulder-,  357 

clinical  relations  of,  351,  358 
sterno-clavicular,  351 
wrist-,  384 

clinical  relations  of,  384 
Jugular  veins.  (See  Veins.) 
Junction,  manubrio-gladiolar,  142 


KIDNEYS,  278 

blood-supply  of,  283 

capsule  of,  278 

clinical  relations  of,  278,  284,  292 

hilum  of  left,  283 

incision  for,  240 

mobility  of,  283 

pelvis  of,  283 
Knee,  housemaid's,  447 

knock-,  454 

Knee-joint,  447,  448,  453 
Knock-knee,  454 
Kohlrausch's  valve,  300 
Kyphosis,  486,  489 


LACHRYMAL  apparatus,  98 

canaliculi,  98 

gland,  98 

puncta,  98 

sac,  98 

Landmarks  of  lower  extremity,  398 
Langenbeck's  incision,  422 
Laryngectomy,  122 
Larynx,  121 

cartilage  of,  121 

clinical  relations  of,  121,  122 

intubation,  122 

laryngectomy,  122 

nerve  supply  of,  121 
Leg,  398,  454 

clinical  relations  of,  454,  461,  482 
Lens,  crystalline,  98 
Leptomeninx,  34 
Ligamenta  denticulata,  498 
Ligaments,  annular  anterior,  of  ankle,  481 
of  wrist,  383 

arcuate,  238 

broad,  of  liver,  250 

coracohumeral,  357 

coronary,  of  liver,  249,  250 

cotyloid,  433 

crucial,  453 

falciform,  of  liver,  250 

hepatoduodenal,  249,  256,  261 

iliopectineal,  234 

infundibulo-pelvic,  310 

lateral,  of  ankle,  481 

lateral,  of  liver,  249 

of  knee-joint,  453 

of  Winslow,  453 

peritoneal,  definition,  249 

phrenocolic,  249,  271,  276 

phrenosplenic,  276 

Poupart's,  196,  208,  234 
relations  under,  428 

suspensory,  of  liver,  250 

teres,  of  hip,  433 
Light  reflex,  53 

Linea  alba  abdominis,  195,  208,  219 
of  pelvis,  288 

semilunaris,  195 

transversae,  195 
Lines,  axillary,  145 
anterior,  145 
posterior,  145 

mammary,  145 

midclavicular,  145 

parasternal,  142 


INDEX. 


509 


Lines,  Roser-Nelaton's,  398 

scapular,  145 

sternal,  142 
lateral,  142 

white,  of  pelvis,  288 
Lips,   70 
Liver,  250 

clinical  relations  of,  215,  250,  261 
Lobes  of  liver,  250 

of  lungs,  191 

of  prostate,  297 
Locomotor  ataxia,  502 
Lordosis,  489 

Lungs,    191.      (See    also    Marking.';,    sur- 
face.} 

blood-supply  of,  191 

clinical  relations  of,  138,  141,  175,  191 

hilum  of,  191 

in  adults,  191 

in  children,  191 

lobes  of,  191 

lymph  supply  of,  191 

root  structures  of,  191 
Lymphatics  of  fingers,  383 

of  hand,  383 
Lymph  glands,  no 


MAGEXDIE'S  foramen,  34 
Main  en  griffe,  392 
Mammary  gland,  154,  176 
Markings,  surface,  aortic,  146,  196 
appendix,  207 
arteries,  aortic,  146,  196 

axillary,  347 

brachial,  348 

carotid,  common,  100,  101 

carotid,  external,  100,  101,  123 

carotid,  internal,  100,  101 

celiac  axis,  199 

cricothyroid,  122 

epigastric,  deep,  199,  219 

facial,  101 

femoral,  417,  443 

iliac,  common,  199 

iliac,  external,  199 

laryngeal,  122 

laryngeal,  inferior,  122 

lingual,  101 

middle  meningeal,  47 

occipital,  10 1 

peroneal,  417 

popliteal,  417 
32 


Markings,  surface,  arteries,  pulmonary,  146 

renal,  199 

subclavian,  101 

temporal,  1 1 

tibial,  anterior,  417 

tibial,  posterior,  417,  468 

thyroid,  superior,  101,  123 
bladder,  288 
bones  of  cranium,  24 
bronchi,  146 

esophagus,  123,  127,  187,  208 
fissures,  interlobar,  of  lungs,  146,  153 

of  Rolando,  47 

of  Sylvius,  47 
fossae,  of  skull,  24 
gall-bladder,  200 
heart,  146,  153 
intestine,  appendix,  207 

large,  207,  272 

small,  200 
kidneys,  207,  208 
liver,  199,  208 
lungs,  146 

interlobar,  fissures  of,  146,  153 

lobes  of,  153 
nerves,  anterior  crural   417 

great  auricular,  102 

great  occipital,  12 

great  sciatic,  417 

median,  348 

musculospiral,  348,  366 

peroneal,  418 

phrenic,  101 

popliteal,  external,  418 

posterior  circumflex,  348 

small  occipital,  102 

spinal  accessory,  101 

superficial  cervical,  ici 

superior  laryngeal,  123 

sympathetic,  of  neck,  102 

tibial,  anterior,  418 

tibial,  posterior,  418 

ulnar,  348 

vagus,  101 
pancreas,  207,  277 
pericardium,  153 
pharynx,  123 
pleura?,  145,  278 
n-(  turn,  272,  299 
sinuses,  lateral,  47 

superior  longitudinal,  47 
spleen,  207,  208 
stomach,  200,  208,  259 


INDEX. 


Markings,  surface,  trachea,  146,  190 
ureters,  207,  284,  291,  305 
valves  of  heart,  146 
veins,  axillary,  348 
femoral,  417,  443 
iliac,  common,  199 
iliac,  external,  199 
jugular,  external,  101 
jugular,  internal,  101 
saphenous,  long,  417 

short,  417 
subclavian,  101 
vena  cava,  inferior,  199 
ventricles  of  heart,  146 
Mastoid,  antrum  of,  54 

cells,  53,  54,  59 
Maxilla,  inferior,  77 
Meati  of  nose,  94 
of  urethra,  295 
Meckel's  ganglion,  78 

diverticulum,  246 
Mediastinum,  192 
contents,  192 
spaces,  192 

Medulla  oblongata,  41,  497 
Membrana  tympani,  53 
Membranes,  costocoracoid,  154,  352 
cricothyroid,  121 
obturator,  428 
of  brain,  33,  34 
of  spinal  cord,  497 
Schrapnell's,  53 
thyrohyoid,  121 
Meninges  of  brain,  33,  34 
clinical  relations  of,  33,  34,  41 
of  spinal  cord,  497 
Mesentery,  definition,  249 
mesocolon,  249,  271 
of  ilium,  249 
of  jejunum,  249 
Middle  ear,  53 

Middle  meningeal  artery,  33,  47 
Morgagni's  columns,  301 
Motion,  center  of,  in  brain,  42 
Mouth,  79 

clinical  relations  of,  79,  80,  85 
floor  of,  87 
vestibule  of,  79 

Muscle,  compressor  urethra,  295 
cremaster,  216 
erector  spinae,  196 
hyoglossus,  no 
intercostals,  153,  154 


Muscle,  latissimus  dorsi,  142,  153 
mylohyoid,   1 10 
oblique,  external,  215 

internal,  216 
of  expression,  68 
of  eyeball,  96 

of  leg,  anterior  region  of,  457 
pectoralis  major,  142,  153 

minor,   153 
rectus  abdominis,  216 
serratus  magnus,   142,   153 
sternocleidomastoid,  100,  115 
sternomastoid,  100,  115 
styloglossus,  no 
transversalis,  216 
trapezius,  100 


NAILS  of  fingers,  384 
Nasal  duct,  98 
Nasopharynx,  89 
Neck,  100 

clinical  relations  of,  100,   101,  102,   109, 
no,    115,    116.     (See    also    Trachea, 
Larynx,  and  Esophagus.') 
examination  of,  100 
fascia.     (See  Fascia.} 
regions  of,  102 
anterior,  102 
lateral,  135 
submaxillary,  109 
surface  markings  of,  101 
Nelaton's  line,  398 
Nerves,  anterior  crural,  240,  417,  428 
anterior  tibial,  457 
auricularis  magnus,  136 
brachial  plexus,  102 

clinical  relations  of,  391 
cranial,  45,  47 
erigentes,  220 
external  cutaneous,  240 
facial,  76 
genitocrural,  240 
great  occipital,  12 

sciatic,  417,  421,  444,  448 
hypoglossal,   no 
iliohypogastric,  234 
ilioinguinal,  234 
intercostal,  163,  164,  220 
intercostohumeral,  164,  352 
laryngeal,  121,  127 

superior,  123 
median,  348,  365,  378 


INDEX. 


Nerves,  musculocutaneous,  of  arm,  366 

of  leg,  458 

musculospiral,  348,  366 
obturator,  240 
occipitalis  minor,  136 
peroneal,  418,  421,  444,  448 

deep,  457 

phrenic,  101,  128,  136,  188,  318 
plantar,  external,  471 

internal,  471 
popliteal,  external,  418,  421,  444,  448 

internal,  418,  421,  444,  448 
posterior  circumflex,  348 
radial,  378 
solar  plexus,  220 
spinal,  498 

accessory,  101 
superficial  cervical,  101,  136 

peroneal,  458 
sympathetic,  of  abdomen,  220,  321 

of  neck,  102 

tibial,  418,  421,  444,  448 
ulnar,  348,  365,  366,  377 
vagus,  101,  128,  189,  318 
Nervi  erigentes,  220 
Neuron,  501 
first  motor,  501 
second  motor,  501 
Nose,  90 

accessory  sinuses  of,  93,  94 
blood-supply  of,  90,  94,  95 
bones  of,  90 

turbinated,  93 
cartilages  of,  90,  93 
clinical  relations  of,  90,  93,  95 
epistaxis,  94 
external  portion,  90 
fractures  of,  95 
internal  portion,  93 
lymphatics  of,  93,  95 
meati,  94 

mucous  membrane  of,  94 
saddle-,  90,  95 
septum,  93 

sinuses  of,  accessory,  93,  94 
turbinated  bones  of,  93 
Nucleus,  caudate,  41 
lenticular,  41 


OMKXTUM,  definition  of,  249 
gastrocolic,  249,  260,  271 
gastrohepatic,  24^ 


Omentum,  gastrosplenic,  260,  276 

greater,  249,  260,  271 

lesser,  249 

Opening,  saphenous,  235 
Optic  thalamus,  41 
Orbit,  95 

clinical  relations  of,  95,  96 
Osteotomy  of  femur,  447 

Macewen's,  447 
Ovary,  310 

blood -supply  of,  310 

lymphatics  of,  310 


PALATE,  cleft,  69,  85,  86 

clinical  relations  of,  69,  85,  86 

hard,  85 

soft,  85 

uvula,  86 
Pancreas,  207,  277 

clinical  relations  of,  245,  262,  265,  277 

relations  of  head  of,  262 
Panniculus  adiposus,  208 
Papillae  of  tongue,  88 
Paralysis  of  nerves  of  brachial  plexus,  391 

of  lower  extremity,  482 
Parotid  region,  76 

gland,  76 

Patches,  Peyer's,  275 
Patella,  clinical  relations  of,  443,  447,  454 
Pelvis,  bones  of,  287 

clinical  relations  of,  287 

diameters  of,  287 

false,  287 

fascia  of,  287 

female,  245,  305 

in  general,  287 

inlet  of,  287 

male,  245,  288 

of  kidney,  283 

outlet  of,  287 

true,  287 

viscera  of,  288 

nerve  supply  of,  220 
Pericardium,  153,  178 
Pericranium,  17,  23 
Peritoneum,  cavity  of,  242,  246,  249 

clinical  relations  of,  242    245,  246 

lymphatic  supply  of,  242 

nerve  supply  of,  241 

parietal,  219,  246 

visceral,  242,  249 
Pes  anserinus,  76 


INDEX. 


Petit's  triangle,  240 
Payer's  patches,  275 
Pharynx,  89,  123 

clinical  relations  of,  89 

lymphoid  tissue  of,  89 

nasopharynx,  89 
Phlebotomy,  369 
Pia-arachnoid,  34 
Pigeon-breast,  138 

Pillars  of  external  abdominal  ring,  215,  225 
Pleura,  145,  189,  278 

sinus  of,  189 
Plexus,  brachial,  102 

prostatic,  of  veins,  297 

solar,  220 

vesical,  of  veins,  297 
Potts'  disease,  485,  493 

fracture,  462,  481 
Pouch,  vesico-uterine,  305 
Poupart's  ligament,  196,  208,  234 
Pregnancy,  extra-uterine,  310 
Process,  coracoid,  142 

ensiform,  196 
Prostate,  297 

clinical  relations  of,  292,  297 
Pubes,  spine  of,  196 
Pulsation  of  brain,  33 
Puncta  lachrymalia,  98 
Pylorus,  259,  260 

clinical  relations  of,  259 


QUADRANGULAR  cartilages  of  nose,  93 


RECTUM,  272,  299 
ampulla  of,  300 
blood  supply  of,  301 
clinical  relations  of,  301 
female,  317 
sphincters  of,  300 
valves  of,  300 

Regions,  axillary,  145 
brachial,  365 
epigastric,  199 
femoral,  234 
gluteal,  398,  418 
hypochondriac,  199 
hypogastric,  199 
iliac,  199,  237 
infra-axillary,   145 
infraclavicular,  145 
inframammary,  145 


Regions,  infrascapular,  145 

inguinal,  225 

interscapular,  145 

lumbar,  199,  240 

mammary,  145 

of  elbow,  369 

of  hip,  398,  418 

of  knee,  447 

of  neck,  lateral,  135 

of  shoulder,  348 

of  thigh,  398 
anterior,  422 

parotid,  76 

perineal,  302 

popliteal,  447 

submaxillary,  109 

supraclavicular,   145 

suprascapular,  145,  362 

umbilical,  199 
Reid's  base  line,  47 
Relations  at  lower  part  of  neck,  127 

of  head  of  pancreas,  262 

of  nerves  to  inguinal  hernia,  234 
of  pelvic  viscera,  288 
Retina,  97 

Retropharyngeal  space,  135 
Ribs,  142 

clinical  relations  of,  138,   142,   154,   164, 

T75 

fractures  of,  164 

resection  of,  175 
Rima  glottidis,  121 

Ring,  abdominal  external,  196,  215,  225 
internal,  225 

crural,  235 

inguinal,  225 

umbilical,  237 
Rolando's  fissure,  47 
Rosary,  rachitic,  141 
Roser-Nelaton  lines,  398 


SAC,  lachrymal,  98 

peritoneal,  242,  246,  247 
Salivary  glands,  no 
Saphenous  opening,  235 

vein.     (See  Veins.) 
Scalp,  17 

blood-supply  of,  18 

clinical  relations  of,  17,  18,  23 

lymph  supply  of,  18 
Scarpa.     (See  Triangle.} 
Schrapnell's  membrane,  53 


INDEX. 


513 


Sclera,  97 

Scoliosis,  489,  493 

Seminal  vesicles.     (See  Vesicle.1;.) 

Sensation,  center  for,  in  brain,  42 

Septum  crurale,  235 

of  nose,  93 
Sheaths,  carotid,  115,  116 

femoral,  234,  235 

of  rectus,  216 

clinical  relations  of,  224 

of  tendons  of  ankle,  468 
of  forearm,  383 
of  sole  of  foot,  472 
Shin,  403 
Shoulder,  examination  of,  322 

-joint.     (See  Joint.) 

region  of,  348 

Sight,  center  of,  in  brain,  42 
Sinew,  weeping,  384 
Sinuses,  accessory,  of  nose,  93,  94 
clinical  relations  of,  94 

costophrenic,  189 

lateral,  47 

of  pleura,  189 

pyriformis,  121 

superior  longitudinal,  47 
Skull.     (See  Cranium  ) 
Snuff-box,  Frenchman's,  347 
Solar  plexus,  220 
Space,  mediastinal,  192 

popliteal,  448 

retropharyngeal,  135 

subarachnoid,  34 

subdural,  34 

submammary,  176 

subphrenic,  245,  250,  276 
Speech,  center  for,  in  brain,  42 
Spermatic  cord,  298 
Spina  bifida,  497 
Spinal  cord,  497 

clinical  relations  of,  501 
columns  of,  501 

segments  of,  498 

localization  of  function  in  (table),  499 
Spine,  484 

clinical  relations  of,  138,  154,  239,  427, 
485,  486,  492,  493.  498 

congenital  defects  of,  497 

contour  of,  486 

deviations  of,  abnormal  anteroposterior, 

493 

lateral,  493 
normal  lateral,  402 


Spine,  examination  of,  484 

functions  of,  486 

in  a  clinical  sense,  486 

movements  of,  normal,  491 

tuberculosis  of,  239 
Spines  of  ilium,  196 

of  pubes,  196 
Spleen,  207,  208,  275 

clinical  relations  of,  276 

wandering,  276 
Splenopexy,  276 
Sprain  of  ankle,  481 
Steno's  duct,  77 
Stenson's  duct,  77 
Sternomastoid,  100,  115 
Sternum,  142 

clinical  relations  of,  138,  142,  164,  175 

fractures  of,  164 
Stomach,  200,  208,  256,  259 

blood-supply  of,  260 

clinical  relations  of,  200,  225,  245,  259 

lymphatic  supply  of,  261 
Stomata  of  peritoneum,  242 
Subarachnoid  space.     (See  Space.) 
Subdural  space,  34 
Submaxillary  glands,  no 

region,  109 

triangle,  109 
Submental  glands,  no 
Suprarenal  capsule,  283 
Surface    markings.     (See    Markings,    sur- 

face.} 

Surgical  guides.     (See  Markings,  surface.) 
Sutures  of  cranium,  24 
Sylvius,  fissure  of,  47 
Syringomyelia,  502 


TABATIERE,  347 

Table  for  referred  pains,  223 

of  localization  of  functions  in  segments 
of  spinal  cord,  499 

of  paralysis  of  lower  extremity,  482 

of  upper  extremity,  392 
Teeth,  80 

clinical  relations  of,  85 

deciduous,  80,  85 

nerve  supply  of,  85 

pi-rmanent,  80,  85 

temporary,  80,  85 
Tegmen  antri,  59 

tympani,  53 

Arhillis,  404,  461 


INDEX. 


Tendon,  conjoined,  216 
Tendon-sheath.     (See  Sheaf/is.) 
Tentorium  cerebelli,  33 
Testis,  298 

blood-supply  of,  298 

clinical  relations  of,  298 

descent  of,  299 

gubernaculum,  299 
Thigh,  443 

clinical  relations  of,  482 
Thoracic  duct,  128,  188 
Thorax,  138 

bony,  138 

examination  of,  141 

muscles  of,  153 

shape  of,  138 

skin  of,  153 

true,  138 
Throat,  cut,  135 
Thymus,  190,  192 
Thyroid,  axis  of,  128 

cartilage,  100,  121 

clinical  relations  of,  124 

gland,  124 
Toe,  clinical  relations  of,  482 

hammer,  482 
Tongue,  88 

adenoid  tissue  of,  88 

blood  supply  of,  88 

clinical  relations  of,  87,  88 

frenum,  87 

mucous  membrane  of,  88 

muscles  of,  88 

nerve  supply  of,  88 

papillae,  88 
Tonsils,  faucial,  86 

blood  supply  of,  87 
clinical  relations  of;  86,  87 

lingual,  88 
Topography,  craniocerebral,  47 

of  cranium,  general,  12 
Trachea,  121,  146,  190 

clinical  relations  of,  121 
Tracheotomy,  123 
Triangles,  Bryant's,  398 

carotid,  inferior,  115 
superior,  115 

Hesselbach's,  233 

Petit's,  240 

Scarpa's,  403 

submaxillary,  109 
Trochanter,  greater,  398 
Tubercle,  carotid,  100 


Tubes,  Fallopian,  309 

clinical  relations  of,  309 

Tunica  vaginalis  communis,  225 
testes,  298 

Tympanic  cavity,  53 
membrane,  53 

Tympanum,  53 


UMBILICUS,  196 

Umbo,  53 

Ureters,  207,  284,  291,  305 

clinical  relations  of,  305 

female,  305 

male,  291 
Urethra,  clinical  relations  of,  295,  302 

male,  295 

Urine,  residual,  292 
Uterus,  306 

blood  supply  of,  310 

clinical  relations  of,  239,  305,  309,  317 

lymphatics  of,  310 
Utricle,  prostatic,  295 
Uvula,  86 


VAGINA,  clinical  relations  of,  305 

examination  of,  during  life,  317 

introitus,  317 
Vagus,  101,  128,  189,  318 
Valves  of  heart,  146,  182 

Heister's,  255 

Houston's,  300 

ileocecal,  272 

Kohlrausch's,  300 
Varicocele,  299 
Vas  deferens,  291,  292,  297 
Vater,  ampulla  of,  262 
Veins,  air  in,  135 

anterior  facial,  no 
tibial,  457 

axillary,  348 

azygos,  163,  1 88 

basilic,  333 

cephalic,  333 

coronary,  of  stomach,  261 

facial,  70 

femoral,  417,  428,  443 

gastric,  261 

gastro-epiploic,  260 

hemiazygos,  188 

iliac,  199 

clinical  relations  of,  240 


INDEX. 


515 


Veins,  innominate,  127 
jugular,  anterior,  115 

external,  100,  101,  128 

internal,  101,  116,  128 
median,  377 
of  back  of  hand,  383 
popliteal,  458 

portal,  clinical  relations  of,  219 
pyloric,  261 
radial,  377 
renal,  283 
saphenous,  double,  458 

external,  417,  458 

internal,  417,  427 
spermatic,  284 
subclavian,  101,  128 
ulnar,  377 
vena  cava,  inferior,  188,  199 

clinical  relations  of,  219 


\Vins,  vena  cava,  superior,  188 
Ventricles  of  brain,  34 

of  heart,  146,  182 
Vesicles,  seminal,  292,  298 

duct  of,  295 
Vestibule  of  mouth,  79 
Viscera.     (See  Abdomen,  Pelvis,  etc.) 
Vitreous,  97 
Volvulus,  272 


WEEPING  sinew,  384 
Wharton's  duct,  no 
Winslow,  foramen  of,  246,  249 
Wrist,  378 
Wrist-drop,  392 
Wrist-joint,  384 
Wry-neck,  congenital,  115 


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JUST  ISSUED— THIRD   EDITION,  REWRITTEN   AND   ENLARGED 

Since  the  appearance  of  the  last  edition  of  this  book  such  rapid  advances 
have  been  made  in  Materia  Medica,  Therapeutics,  and  the  allied  sciences  that 
the  author  felt  it  imperative  to  rewrite  the  work  entirely.  All  the  newer  reme- 
dies that  have  won  approval  by  recognized  authorities  have  been  incorporated, 
and  their  therapeutic  properties  fully  discussed,  thus  bringing  the  book  absolutely 
down  to  date.  The  work  includes  the  following  sections  :  Physiologic  Action  of 
Drugs  ;  Drugs  ;  Remedial  Measures  other  than  Drugs  ;  Applied  Therapeutics  ; 
Incompatibility  in  Prescriptions  ;  Table  of  Doses  ;  Index  of  Drugs  ;  and  Index 
of  Diseases  ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 


OPINIONS  OF  THE  MEDICAL  PRESS 


University  Medical  Magazine 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work  .  .  . 
and  it  will  be  found  a  reliable  guide  and  sufficiently  comprehensive  for  the  physician  in 
practice." 

Bristol  Medico-Chirurgical  Journal,  Bristol 

"This  addition  to  the  numerous  .works  on  Therapeutics  is  distinctly  a  good  one.  ...  It 
is  to  be  recommended  as  being  systematic,  clear,  concise,  very  fairly  up  to  date,  and  carefully 
indexed." 


Monro's  Manual  of  Medicine  just  issued 

Manual  of  Medicine.  By  THOMAS  KIRKPATRICK  MONRO,  M.  A.,  M.  D., 
Fellow  of,  and  Examiner  to,  the  Faculty  of  Physicians  and  Surgeons, 
England  ;  Glasgow  Physician  to  Glasgow  Royal  Infirmary,  Glasgow,  etc. 
Octavo  volume  of  901  pages,  illustrated.  Cloth,  $5.00  net. 


SAUNDERS*   BOOKS   ON 


Saunders' 
Pocket  Medical  Formulary 


Sixth  Edition,  Revised 


Saunders'  Pocket  Medical  Formulary.  By  WILLIAM  M.  POWELL, 
M.  D.,  author  of  "  Essentials  of  Diseases  of  Children  " ;  Member  of 
Philadelphia  Pathological  Society.  Containing  1 844  formulas  from  the 
best-known  authorities.  With  an  Appendix  containing  Posological 
Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons 
and  their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal  Head, 
Obstetrical  Table,  Diet-lists,  Materials  and  Drugs  used  in  Antiseptic 
Surgery,  Treatment  of  Asphyxia  from  Drowning,  Surgical  Remem- 
brancer, Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc.  In  flex- 
ible morocco,  with  side  index,  wallet,  and  flap.  $2.00  net. 

CONTAINING  200  NEW  FORMULAS 

In  compiling  this  handy  volume  the  author  has  introduced  as  many  of  the 
more  important  recently  discovered  drugs  as  possible.  Besides  the  many  hun- 
dreds of  famous  formulas  collected  from  the  works  of  the  most  eminent  physicians 
and  surgeons  of  the  world,  it  contains  many  valuable,  and  hitherto  unpublished, 
prescriptions  from  the  private  practice  of  distinguished  practitioners  of  to-day. 
In  this  new  edition  the  work  has  been  thoroughly  and  carefully  revised  and  cor- 
rected, and  some  two  hundred  new  and  valuable  formulas  added.  The  Dose- 
table  has  been  brought  up  to  date,  and  the  entire  work  made  to  comply  in  every 
way  with  the  latest  knowledge  on  the  subjects  it  contains. 


OPINIONS  OF  THE   MEDICAL  PRESS 


Medical  Record,  New  York 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and,  as  the  name  of  the  author  of  each  prescription  is 
given,  is  unusually  reliable." 

Johns  Hopkins  Hospital  Bulletin 

"  Arranged  in  such  a  way  as  to  make  consultation  of  it  as  easy  as  possible.  It  is  remark- 
able how  much  information  the  author  has  succeeded  in  getting  into  so  small  a  book." 

Boston  Medical  and  Surgical  Journal 

"  The  book  is  attractively  bound  in  flexible  leather,  and  the  fact  that  it  has  reached  its 
sixth  edition  bears  ample  testimony  to  its  popularity." 


THE  PRACTICE   OF  MEDICINE 


Anders* 
Practice  of  Medicine 

Sixth  Revised  Edition — Just  Issued 


A  Text-Book  of  the  Practice  of  Medicine.  By  JAMES  M.  ANDERS, 
M.  D.,  PH.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1295  pages,  fully  illustrated.  Cloth,  $5.50  net;  Sheep 
or  Half  Morocco,  $6.50  net. 

SIX   EDITIONS   IN   SIX  YEARS 

The  success  of  this  work  as  a  text-book  and  as  a  practical  guide  for  physi- 
cians has  been  truly  phenomenal,  six  large  editions  having  been  called  for 
in  as  many  years.  The  rapid  exhaustion  of  each  edition  has  made  it  possible 
to  keep  the  book  absolutely  abreast  of  the  times,  so  that  Anders'  Practice  has 
become  justly  celebrated  as  the  most  up-to-date  work  on  practice.  In  this 
edition  Malaria,  Yellow  Fever,  Bacillary  Dysentery,  Cholecystitis,  and  the  use  of 
the  X-rays  in  Diagnosis  and  Treatment  have  been  fully  discussed,  incorporating  the 
results  of  the  most  recent  investigations.  Among  the  new  subjects  introduced  are 
Paratyphoid  Fever,  the  Fourth  Disease,  Trypanosomiasis,  Orthostatic  Albuminuria, 
Transcortical  Aphasia,  Adiposis  Dolorosa,  and  Amaurotic  Family  Idiocy,  particu- 
lar attention  being  paid  to  clinical  character,  diagnosis,  and  treatment. 


PERSONAL  OPINIONS 


James  C.  Wilson,  M.  D.. 

Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Jefferson  Medical  College 

Philadelphia. 

"  It  is  an  excellent  book — concise,  comprehensive,  thorough,  and  up-to-date.  It  is  a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 

A.  C.  Cowperthwait,  M.  D.. 

President  Illinois  Homeopathic  Medical  Association. 

"  I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by  far 
the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up-to-date 
in  everything.  I  consider  it  a  great  credit  to  both  the  author  and  the  publishers." 

George  Roe  Lock  wood.  M.  D.. 

Attending  Physician  to  the  Bellevue  Hospital,  New  York. 

"  I  have  read  several  of  the  important  chapters  carefully,  and  am  very  much  pleased  with 
the  work.  It  is  thoroughly  up-to-date,  well  expressed,  and  shows  evidence  of  clinical  expe- 
rience." 


SAUNDERS'    BOOKS   ON 


AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

UNDER   THE   EDITORIAL   SUPERVISION    OF 

ALFRED   STENGEL,  M.D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Physician  to  the  Pennsylvania  Hospital. 


BEST  IN 
EXISTENCE 


FOR  THE 
PRACTITIONER 


It  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal  Medicine ;  and 
of  all  the  German  works  on  this  subject,  Nothnagel's  "  Specielle  Pathologic  und  Therapie" 
is  conceded  by  scholars  to  be  without  question  the  best  Practice 
of  Medicine  in  existence.  So  necessary  is  this  book  in  the  study 
of  Internal  Medicine  that  it  comes  largely  to  this  country  in  the 
original  German.  In  view  of  these  facts,  Messrs.  W.  B.  Saunders  & 
Company  have  arranged  with  the  publishers  of  the  German  edition 
to  issue  at  once  an  authorized  American  edition  of  this  great  Practice  of  Medicine. 

For  the  present  a  set  of  n  volumes,  selected  with  especial  thought  of  the  needs  of  the 
practising  physician,  will  be  published.  These  volumes  will  con- 
tain the  real  essence  of  the  entire  work,  and  the  purchaser  will 
therefore  obtain,  at  less  than  half  the  cost,  the  cream  of  the  orig- 
inal. Later  the  special  and  more  strictly  scientific  volumes  will 
be  offered  from  time  to  time. 
The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist.  It  will  thus  be  brought 
thoroughly  up  to  date,  and  the  American  edition  will  be  more  than  a  mere  translation ;  for, 
in  addition  to  the  matter  contained  in  the  original,  it  will  represent 
the  very  latest  views  of  the  leading  American  and  English  special- 
ists in  the  various  departments  of  Internal  Medicine.  Moreover, 
as  each  volume  will  be  revised  to  the  date  of  its  publication  by  the 
eminent  editor,  the  objection  that  has  heretofore  existed  to  treatises 
published  in  a  number  of  volumes  will  be  obviated,  since  the  subscriber  will  receive  the  com- 
pleted work  while  the  earlier  volumes  are  still  fresh.  The  American  publication  of  the  entire 
work  is  under  the  editorial  supervision  of  Dr.  ALFRED  STENGEL,  who  has  selected  the  subjects 
for  the  American  Edition,  and  has  chosen  the  editors  of  the  different  volumes. 

The  usual  method  of  publishers  when  issuing  a  publication  of 
this  kind  has  been  to  require  physicians  to  take  the  entire  work. 
This  seems  to  us  in  many  cases  to  be  undesirable.  Therefore,  in 
purchasing  this  Practice  physicians  will  be  given  the  opportunity 
of  subscribing  for  it  in  entirety ;  but  any  single  volume  or  any 
number  of  volumes,  each  complete  in  itself,  may  be  obtained  by  those  who  do  not  desire  the 
complete  series.  This  latter  method  offers  to  the  purchaser  many  advantages  which  will  be 
appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

SEE  NEXT  TWO  PAGES  FOR  LIST 


PROMINENT 
SPECIALISTS 


VOLUMES  SOLD 
SEPARATELY 


PRACTICE   OF  MEDICINE. 


AMERICAN  EDITION 

NOTHNAGEL'S  PRACTICE 

VOLUMES   NOW  READY 


Typhoid  and  Typhus  Fevers 

By  DR.  H.  CURSCHMANN,  Professor  of  Medicine  in  Leipsic.  The  entire 
volume  edited,  with  additions,  by  WILLIAM  OSLER,  M.  D.,  F.  R.  C.  P., 
Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  Univer- 
sity, Baltimore.  Octavo,  646  pages,  illustrated.  Cloth,  $5.00  net ;  Half 
Morocco,  $6.00  net. 

"Under  the  editorial  supervision  of  Dr.  Osier,  the  original  German  work,  excellent 
though  it  is,  has  been  much  improved,  greatly  enlarged,  and  enhanced  in  value,  espe- 
cially to  American  readers.  .  .  .  The  monograph  on  typhoid  fever  is  the  best  exponent 
of  the  knowledge  that  we  have  in  regard  to  this  disease  that  is  to  be  had  in  any  lan- 
guage."— Journal  of  the  American  Medical  Association. 

Smallpox  (including  Vaccination),  Varicella,  Cholera  Asiatica, 
Cholera  Nostras,  Erysipelas,  Erysipeloid,  Pertussis,  and 
Hay  Fever 

By  DR.  H.  IMMERMANN,  of  Basle  ;  DR.  TH.  VON  JURGENSEN,  of  Tubin- 
gen ;  DR.  C.  LIEBERMEISTER,  of  Tubingen  ;  DR.  H.  LENHARTZ,  of  Ham- 
burg ;  and  DR.  G.  STICKER,  of  Giessen.  The  entire  volume  edited,  with 
additions,  by  SIR  J.  W.  MOORE,  M.  D.,  F.  R.  C.  P.  I.,  Professor  of  Prac- 
tice, Royal  College  of  Surgeons,  Ireland.  Octavo,  682  pages,  illustrated. 
Cloth,  $5.00  net ;  Half  Morocco,  $6.00  net. 

"  Dr.  Immermann's  vindication  of  vaccination  in  the  prophylaxis  of  smallpox  will  be 
read  with  peculiar  interest  at  the  present  time,  since  it  is  probably  the  most  complete 
and  unassailable  indictment  of  the  propaganda  of  antivaccination  fanatics  which  has  ever 
been  published." — The  London  Lancet. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  WILLIAM  P.  NORTHRUP,  M.  D.,  of  New  York,  and  DR.  TH.  VON 
JURGENSEN,  of  Tubingen.  The  entire  volume  edited,  with  additions,  by 
WILLIAM  P.  NORTHRUP,  M.  D.,  Professor  of  Pediatrics,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  Octavo,  672  pages,  illus- 
trated, including  24  full-page  plates,  3  in  colors.  Cloth,  $5.00  net;  Half 
Morocco,  $6.00  net. 

"  The  author  is  to  be  congratulated  on  the  exhaustive  and  practical  manner  in  which 
he  presents  the  subject.  .  .  .  The  articles  on  measles,  scarlet  fever,  and  German  measles 
are  exhaustive  treatises,  with  numerous  additions  by  the  American  editor." — Journal 
of  the  American  Medical  Association. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and  In- 
flammations of  the  Lungs 

By  DR.  F.  A.  HOFFMANN,  of  Leipsic  ;  DR.  O.  ROSENBACH,  of  Berlin  ;  and 
DR.  F.  AUFRECHT,  of  Magdeburg.  The  entire  volume  edited,  with  additions, 
by  JOHN  H.  MUSSER,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Octavo,  1029  pages,  illustrated,  including  7  full-page  colored 
lithographic  plates.  Cloth,  £5.00  net  ;  Half  Morocco,  56.00  net. 

"  These  monographs  in  the  original  hold  an  enviable  place  in  German  medical  literature, 
each  one  being  exhaustive,  complete,  authoritative,  and  \\ritu-n  by  men  specially  fitted  for 
the  work.  But  the  American  edition  is  not  only  a  reproduction  in  English,  it  is  all  of  this 
and  more ;  for  the  American  editor  has  added  much  of  value  not  included  in  the  original, 
and  he  has  brought  every  part  thoroughly  up  to  date." — Journal  of  the  American  Medical 
Association. 


io  SAUNDERS'   BOOKS   ON 

AMERICAN   EDITION 

NOTHNAGEL'S   PRACTICE 

VOLUMES  NOW  READY  AND  IN  PRESS 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  DR.  L.  OSER,  of  Vienna  ;  DR.  E.  NEUSSER,  of  Vienna,  and  DRS.  H. 
QUINCKE  and  G.  HOPPE-SEYLER,  of  Kiel.  The  entire  volume  edited,  with 
additions,  by  REGINALD  H.  FITZ,  A.  M.,  M.  D.,  Hersey  Professor  of  the 
Theory  and  Practice  of  Physic,  Harvard  University  ;  and  FREDERICK  A. 
PACKARD,  M.  D.,  Late  Physician  to  Pennsylvania  and  Children's  Hospitals. 
Octavo  of  918  pages,  illustrated.  Cloth,  $5.00  net ;  Half  Morocco,  $6.00  net. 

"  It  aims  to  review  the  relation  of  medical  practice  to  normal  and  pathological  physiology, 
and  its  copious  bibliography  makes  the  literature  of  each  subject  available." — Johns  Hop- 
kins Hospital  Bulletin. 

Diseases  of  the  Stomach 

By  DR.  F.  RIEGEL,  of  Giessen.  Edited,  with  additions,  by  CHARLES  G. 
STOCKTON,  M.  D.,  Professor  of  Medicine,  University  of  Buffalo.  Handsome 
octavo  of  835  pages,  with  29  text-cuts  and  6  full-page  plates.  Cloth,  $5.00 
net ;  Half  Morocco,  $6.00  net. 

This  work  is  a  complete  exposition  of  the  diseases  of  the  stomach.  Full  consideration 
is  given  to  the  hydrochloric  acid  question,  the  latest  views  being  incorporated  by  the 
editor.  Particular  attention  has  been  given  to  disturbances  of  motility  and  secretion. 

Diseases  of  the  Intestines  and  Peritoneum 

By  DR.  HERMANN  NOTHNAGEL,  of  Vienna.  The  entire  volume  edited,  with 
additions,  by  H.  D.  ROLLESTON,  M.  D.,  F.  R.  C.  P.,  Physician  to  St.  George's 
Hospital,  London.  Octavo  of  800  pages,  finely  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  DR.  G.  CORNET,  of  Berlin.  Edited,  with  additions,  by  WALTER  B. 
JAMES,  M.  D.,  Professor  of  the  Practice  of  Medicine,  Columbia  University, 
New  York.  Handsome  octavo  of  700  pages. 

Influenza,  Dengue,  Malarial   Diseases 

By  DR.  O.  LEICHTENSTERN,  of  Cologne,  and  DR.  J.  MANNABERG,  of  Vienna. 
The  entire  volume  edited,  with  additions,  by  RONALD  Ross,  F.  R.  C.  S.,  ENG., 
D.  P.  H.,  F.  R.  S.,  Major,  Indian  Medical  Service,  retired;  Walter  Myers 
Lecturer,  Liverpool  School  of  Tropical  Medicine,  Liverpool.  Handsome 
octavo  of  700  pages,  with  7  full-page  lithographic  plates  in  colors. 

Anemia,    Leukemia,    Pseudoleukemia,   Hemoglobinemia,  and 
Chlorosis 

By  DR.  P.  EHRLICH,  of  Frankfort-on-the-Main  ;  DR.  A.  LAZARUS,  of  Char- 
lottenburg  ;  DR.  FELIX  PINKUS,  of  Berlin  ;  and  DR.  K.  VON  NOORDEN,  of 
Frankfort-on-the-Main.  The  entire  volume  edited,  with  additions,  by  ALFRED 
STENGEL,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 
Handsome  octavo  of  750  pages,  with  5  full-page  lithographs  in  colors. 

Diseases  of  Kidneys  and  Spleen,  and  Hemorrhagic  Diatheses 

By  DR.  H.  SENATOR,  of  Berlin,  and  DR.  M.  LITTEN,  of  Berlin.  The  entire 
volume  edited,  with  additions,  by  JAMES  B.  HERRICK,  M.  D.,  Professor  of  the 
Practice  of  Medicine,  Rush  Medical  College,  in  affiliation  with  the  University 
of  Chicago.  Octavo  of  800  pages,  finely  illustrated. 

EACH  VOLUME  IS  COMPLETE  IN  ITSELF  AND  IS  SOLD  SEPARATELY 


THE  PRACTICE  OF  MEDICINE  11 

Eichhorst's 
Practice  of  Medicine 

A  Text-Book  of  the  Practice  of  Medicine.  By  DR.  HERMANN  EICH- 
HORST,  Professor  of  Special  Pathology  and  Therapeutics  and  Director 
of  the  Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by 
AUGUSTUS  A.  ESHNER,  M.  D.,  Professor  of  Clinical  Medicine,  Phila- 
delphia Polyclinic.  Two  octavo  volumes  of  600  pages  each,  with  over 
1 50  illustrations.  Price  per  set :  Cloth,  $6.00  net ;  Sheep  or  Half 
Morocco,  $7.50  net. 

BY  ONE  OF  THE  GREATEST  OF  GERMAN   CLINICIANS 

This  book  is  a  new  one,  but  on  its  publication  it  sprang  into  immediate 
popularity,  and  is  now  one  of  the  leading  text-books  in  Germany.  It  is  prac- 
tically a  condensed  edition  of  the  author's  great  work  on  Special  Pathology  and 
Therapeutics,  and  it  forms  not  only  an  ideal  text-book  for  students,  but  a  practical 
guide  of  unusual  value  to  practising  physicians. 

Bulletin  of  Johns  Hopkins  Hospital 

"This  book  is  an  excellent  one  of  its  kind.  Its  completeness,  yet  brevity,  the  clinical 
methods,  the  excellent  paragraphs  on  treatment  and  watering-places,  will  make  it  very  desir- 
able." 


Bridge  on  Tuberculosis 

Tuberculosis.  By  NORMAN  BRIDGE,  A.M.,  M.  D.,  Emeritus  Pro- 
fessor of  Medicine  in  Rush  Medical  College,  in  affiliation  with  the 
University  of  Chicago.  I2mo  of  302  pages,  illustrated.  Cloth, 
$1.50  net. 

RECENTLY   ISSUED 

In  this  excellent  work  the  practical  side  of  the  care  and  management  of  those 
sick  with  the  various  non-surgical  forms  of  tuberculosis  has  been  concisely  stated. 
Full  consideration  has  been  given  to  prophylaxis,  an  all-important  phase  of  the 
subject  that  has  heretofore  been  much  neglected.  There  are  also  chapters  upon 
the  Bacillus  of  Tuberculosis  ;  on  the  Pathology,  Etiology,  Symptoms,  Physical 
Signs,  Diagnosis,  and  Prognosis  of  the  disease. 

Johns  Hopkins  Hospital  Bulletin 

"  The  book  is  simply,  clearly,  and  pleasantly  written.  .  .  .  Full  of  good  sense,  which  no 
one  will  read  without  profit." 


12  SAUNDERS'  BOOKS   ON 

Sollmann's  Pharmacology 

Including  Therapeutics,  Materia  Medica.  Pharmacy, 
Prescription -writing,  Toxicology,  etc. 


A  Text-Book  of  Pharmacology.  By  TORALD  SOLLMANN,  M.  D., 
Assistant  Professor  of  Pharmacology  and  Materia  Medica,  Medical 
Department  of  Western  Reserve  University,  Cleveland,  Ohio.  Hand- 
some octavo  volume  of  894  pages,  fully  illustrated.  Cloth,  $3.75  net. 

A   NEW  WORK— RECENTLY   ISSUED 

This  work  aims  to  furnish  a  scientific  discussion  and  definite  conception  of  the 
action  of  drugs,  as  well  as  their  derivation,  composition,  strength,  and  dose.  The 
author  bases  the  study  of  therapeutics  on  a  systematic  knowledge  of  the  nature 
and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  F.  Fotheringh&m,  M.  D. 

Prof,  of  Therapeutics  and  Theory  and  Practice  of  Prescribing,  Trinity  Med.  College,  Toronto. 
"The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Butler's   Materia   Medica 

Therapeutics,  and  Pharmacology 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology. 

By  GEORGE  F.  BUTLER,  PH.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago, 
Octavo,  896  pages,  illustrated.  Cloth,  $4.00  net ;  Sheep  or  Half  Morocco, 
$5.00  net. 

FOURTH   EDITION,  REVISED  AND   ENLARGED 

In  this  new  edition  the  chapters  on  Organo-therapy,  Serum-therapy,  and  cog- 
nate subjects  have  been  enlarged  and  carefully  revised.  An  important  addition 
is  the  chapter  devoted  to  the  newer  theories  of  electrolytic  dissociation  and  its 
relation  to  the  topic  of  pharmacotherapy. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the  com- 
pleteness of  the  text,  and  the  student  or  general  reader  is  given  the  benefit  of  latest  advices 
bearing  upon  the  value  of  drugs  and  remedies  considered." 


THE  PRACTICE   OF  MEDICINE.  13 

Gould   and  Pyle's 
Curiosities  of  Medicine 


Anomalies  and  Curiosities  of  Medicine.  By  GEORGE  M.  GOULD, 
M.  D.,  and  WALTER  L.  PYLE,  M.  D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages,  295  engravings,  and  12  full-page  plates. 

Popular  Edition  :  Cloth,  $3.00  net  ;  Sheep  or  Half  Morocco,  $4-00  net. 

As  a  complete  and  authoritative  Book  of  Reference  this  work  will  be  of  value 
not  only  to  members  of  the  medical  profession,  but  to  all  persons  interested  in 
general  scientific,  sociologic,  and  medicolegal  topics  ;  in  fact,  the  absence  of  any 
complete  work  upon  the  subject  makes  this  volume  one  of  the  most  important 
literary  innovations  of  the  day. 

The  Lancet,  London 

"The  book  is  a  monument  of  untiring  energy,  keen  discrimination,  and  erudition.  .  .  . 
We  heartily  recommend  it  to  the  profession." 

Saunders'  Year-Book 


The  American  Year-Book  of  Medicine  and  Surgery.  A  Yearly 
Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all  branches 
of  Medicine  and  Surgery,  drawn  from  journals,  monographs,  and  text- 
books of  the  leading  American  and  foreign  authors  and  investigators. 
Arranged  with  critical  editorial  comments  by  eminent  American  special- 
ists, under  the  editorial  charge  of  GEORGE  M.  GOULD,  M.  D.  In  two 
volumes — Vol.  I.,  including  General  Medicine ;  Vol.  II.,  General  Sur- 
gery. Per  volume  :  Cloth,  $3.00  net;  Half  Morocco,  $3.75  net.  Sold 
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experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commen- 
taries and  expositions  .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


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Thornton's   Dose-Book 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  THORN- 
TON, M.  D.,  Assistant  Professor  of  Materia  Medica,  Jefferson  Medical 
College,  Phila.  Post-octavo,  362  pages,  illustrated.  Flexible  Leather, 
$2.00  net. 

Second  Edition,  Revised  and  Enlarged 

In  the  new  edition  of  this  work,  intended  for  the  student  and  practitioner, 
additions  have  been  made  to  the  chapters  on  ' '  Prescription-Writing ' '  and 
1 '  Incompatibilities, ' '  and  references  have  been  introduced  in  the  text  to  the 
newer  curative  sera,  organic  extracts,  synthetic  compounds,  and  vegetable  drugs. 
To  the  Appendix,  chapters  upon  Synonyms  and  Poisons  and  their  antidotes 
have  been  added,  thus  increasing  its  value  as  a  book  of  reference. 

C.  H.   Miller,  M.  D., 

Professor  of  Pharmacology,  Northwestern  University  Medical  School,  Chicago. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recommend 
the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text-books." 


American  Text-Book  of 
Applied  Therapeutics 

American  Text- Book  of  Applied  Therapeutics.  Edited  by  JAMES 
C.  WILSON,  M.  D.,  Professor  of  Practice  of  Medicine  and  of  Clinical 
Medicine,  Jefferson  Medical  College,  Philadelphia.  Handsome  imperial 
octavo  volume  of  1326  pages.  Illustrated.  Cloth,  $7.00  net;  Sheep 
or  Half  Morocco,  $8.00  net. 

For  Student  and  Practitioner 

Written  for  both  the  student  and  practitioner,  the  aim  of  this  work  is  to 
facilitate  the  application  of  knowledge  to  the  prevention,  cure,  and  alleviation 
of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of  the 
book — "Applied  Therapeutics  " — to  indicate  the  course  of  treatment  to  be  pur- 
sued at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used  at 
one  time  or  another.  The  work  will  be  found  accurate  and  trustworthy. 

Buffalo  Medical  Journal 

"  It  is  one  of  the  most  complete  books  of  reference  that  has  been  presented  to  the  profes- 
sion on  medicine  in  a  long  period  of  time  ;  and  never  before  have  we  had  one  that  undertook 
to  cover  the  field  in  this  manner." 


PRACTICE,  MATERIA    MED  1C  A,  Etc. 


The  American  Pocket  Medical  Dictionary.    4th  Edition,  just  Ready 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited  by  W.  A.  NEWMAN  DOR- 
LAND,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the  University  of  Pennsylvania. 
Containing  the  pronunciation  and  definition  of  the  principal  words  used  in  medicine 
and  kindred  sciences,  with  64  extensive  tables.  Flexible  leather,  with  gold  edges, 
$l.oo  net ;  with  thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  Holland,  M.  D.,  Dean  of  the 
Jefferson  Medical  College,  Philadelphia. 

Vierordt's   Medical   Diagnosis.      Fourth  Edition.  Revised 

MEDICAL  DIAGNOSIS.  By  DR.  OSWALD  VIERORDT,  Professor  of  Medicine,  Univer- 
sity of  Heidelberg.  Translated  from  the  fifth  enlarged  German  edition  by  FRANCIS 
H.  STUART,  A.  M.,  M.  D.  Octavo,  603  pages,  104  wood  cuts.  Cloth,  $4.00  net; 
Sheep  or  Half  Morocco,  $5.00  net. 

"  Has  been  recognized  as  a  practical  work  of  the  highest  value.  It  may  be  considered  indispensable 
both  to  students  and  practitioners." — F.  Minot,  M.  D.,  late  Professor  of  Theory  and  Practice  in 

Harvard  University. 

Cohen  and  Eshner's  Diagnosis.     Second  Revised  Edition 

ESSENTIALS  OF  DIAGNOSIS.  By  S.  SOLIS-COHEN,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  ESHNER,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.  Cloth,  $1.00  net.  In  Saunders'1  Question- Compend  Series. 

"Concise  in  the  treatment  of  subject,  terse  in  expression  of  fact." — American  Journal  of  the 
Medical  Sciences. 

Morris*  Materia  Medica  and  Therapeutics.    Fifth  Revised  Edition 

ESSENTIALS  OF  MATERIA  MEDICA,  THERAPEUTICS,  AND  PRESCRIPTION-WRITING. 
By   HENRY   MORRIS,  M.   D.,  late   Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.      Post-octavo,  250   pages.     Cloth,  $I.OO  net.      In  Saunders1  Question- 
Compend  Series. 
"  Cannot  fail  to  impress  the  mind  and  instinct  in  a  lasting  manner. " — Buffalo  Medical  Journal. 

Sayre's  Practice  of  Pharmacy.    Second  Edition,  Revised 

ESSENTIALS  OF  THE  PRACTICE  OF  PHARMACY.  By  Lucius  E.  SAYRE,  M.  D.,  Pro- 
fessor of  Pharmacy,  University  of  Kansas.  Post-octavo,  200  pages.  Cloth,  $i.oonet. 
In  Saunders1  Question- Compend  Series. 

"  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful  student's 
manual." — Boston  Medical  and  Surgical  Journal. 

Brockway's   Medical    Physics.      Second  Edition,  Revised 

ESSENTIALS  OF  MEDICAL  PHYSICS.  By  FRED.  J.  BROCKWAY,  M.  D.,  late  Assistant 
Demonstrator  of  Anatomy,  College  of  Physicians  and  Surgeons,  N.  Y.  Post-octavo, 
33°  Pages  ;  X55  fine  illustrations.  Cloth,  $1.00  net.  In  Saunders'  Question- Compend 
Series. 

"  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously  illustrated." — 
Medical  Record,  New  York. 

Stoney's  Materia  Medica  for  Nurses 

MATERIA  MEDICA  FOR  NURSES.  By  EMILY  A.  M.  STONEY,  Superintendent  of  the 
Training  School  for  Nurses  at  the  Carney  Hospital,  South  Boston,  Mass.  Handsome 
octavo  volume  of  306  pages.  Cloth,  $l.f>O  net. 

"It  contains  about  everything  that  a  nurse  ought  to  know  in  regard  to  drugs."— Journal  of  the 
American  Medical  Association. 

Grafstrom's  Mechano-therapy 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (Massage  and  Medical  Gymnastics).  By 
AXEL  V.  GRAFSTROM,  B.  Sc.,  M.  D.,  late  House  Physician,  City  Hospital,  Black- 
well's  Island,  N.  Y.  I2mo,  139  pages,  illustrated.  $1.00  net. 

'•'  Certainly  fulfills  its  mission  in  rendering  comprehensible  the  subjects  of  massage  and  medical 
gymnastics.  — New  York  Medical  Journal. 


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Jakob  and  Cshner's  Internal  Medicine  and  Diagnosis 

ATLAS  AND  EPITOME  OF  INTERNAL  MEDICINE  AND  CLINICAL  DIAGNOSIS.  By  DR. 
CHR.  JAKOB,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  ESHNER,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  182  colored  figures  on 
68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth,  $3.00  net.  In  Saunders1 
Hand-  Atlas  Series. 

"  Can  be  recommended  unhesitatingly  to  the  practicing  physician  no  less  than  to  the  student."  — 
Bulletin  of  Johns  Hopkins  Hospital. 


Lockwood's  Practice  of  Medicine. 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.  By  GEO.  ROE  LOCKWOOD,  M.  D., 
Attending  Physician  to  the  Bellevue  Hospital,  New  York  City.  Octavo,  847  pages, 
with  79  illustrations  in  the  text  and  22  full-page  plates.  Cloth,  #4.00  net. 

"  A  work  of  positive  merit,  and  one  which  we  gladly  welcome."  —  New  York  Medical  Journal. 

Salinger  and  Kalteyer's  Modern  Medicine 

MODERN  MEDICINE.  By  JULIUS  L.  SALINGER,  M.  D.,  late  Ass't  Prof,  of  Clinical 
Medicine,  Jefferson  Medical  College;  and  F.  J.  KALTEYEK,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College.  Handsome  octavo,  801  pages,  illus- 
trated. Cloth,  $4.00  net. 

"  I  have  carefully  examined  the  book,  and  find  it  to  be  thoroughly  trustworthy  in  all  respects  and  a 
valuable  text-book  for  the  medical  student."  —  Sam'l  O.  L.  Potter,  Formerly  Professor  of  Principles 
and  Practice  of  Medicine,  Cooper  Medical  College,  San  Francisco. 

Keating's  Life  Insurance 

How  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  the  late  JOHN  M.  KEATING,  M.  D., 
Ex-President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal  octavo, 
211  pages.  With  numerous  illustrations.  Cloth,  $2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination."  —  Medical 
News. 

Oorwin's   Physical   Diagnosis.      Third  Edition,  Revised 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OK  THE  THORAX.  By  A.  M.  CORWIN,  A.  M., 
M.  D.,  Professor  of  Physical  Diagnosis,  College  of  Physicians  and  Surgeons,  Chicago. 
220  pages,  illustrated.  Cloth,  flexible  covers,  $1.25  net. 

"  A  most  excellent  little  work.  It  arranges  orderly  and  in  sequence  the  various  objective  phenomena 
to  logical  solution  of  a  careful  diagnosis."—  Journal  of  Nervous  and  Mental  Diseases. 

American  Text-Book  of  Theory  and  Practice 

AMERICAN  TEXT-BOOK  OF  THE  THEORY  AND  PRACTICE  OF  MEDICINE.  Edited 
by  the  late  WILLIAM  PEPPER,  M.  D.,  LL.  D.,  Professor  of  the  Theory  and  Practice 
of  Medicine  and  of  Clinical  Medicine,  University  of  Penna.  Two  handsome  imperial 
octavos  of  about  looo  pages  each.  Illustrated.  Per  volume  :  Cloth,  $5.00  net  ;  Sheep 
or  Half  Morocco,  $6.00  net. 

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Practice  of  Medicine,  University  of  the  City  of  New  York. 

Stevens'  Practice  Of   Medicine.      Sixth  Edition,  Revised—  Just  Issued 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.  By  A.  A.  STEVENS,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis,  University  of  Pennsylvania.  Specially  intended  for 
students  preparing  for  graduation  and  hospital  examinations.  Post-octavo,  556  pages  ; 
illustrated.  Flexible  leather,  $2.25  net. 

"  An  excellent  condensation  of  the  essentials  of  medical  practice  for  the  student,  and  may  be  found 
also  an  excellent  reminder  for  the  busy  physician."  —  Buffalo  Medical  Journal. 


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